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Full text of "A treatise on cystoscopy and urethroscopy"

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1 lIBRASfES 1 




HEALTH 



Digitized by the Internet Archive 

in 2010 with funding from 

Open Knowledge Commons 



http://www.archive.org/details/treatiseoncystosOOIuys 



TREATISE ON 
CYSTOSCOPY AND URETHROSCOPY 



WORKS BY THE SAxME AUTHOR 

TllAITE DE LA BLENNORRAGIE ET CE SES COMPLICATIONS. 

Second edition, revised and enlarged. One large volume, Svo., containing 
620 pages, with 215 figures in the text and 3 colored plates. .1-2 Francs 
(Crowned by the Academy of Medicine, Ricord Prize, 191.3.) 

Exploration de l 'Appareil urinaire. 

Second edition, revised and enlarged. One volume of GIO pages, with 

226 figures in the text and 6 colored plates 20 Francs 

(Crowned by the Academy of Medicine of Paris, Laborie Prize, 1907.) 

La Separation de l 'Urine des ueux reins. 

One volume, Svo., with 55 figures in the text 6 Fiancs 



A TKI]ATISI] 

ON 

CVXTOSCOl'Y AND UliKTHliOSCOl'V 



f 



BY 

mi. GEORGES LUYS 

FOKMKll IXTKKXE, HOSPITALS OF PARIS; FOr>.JIEK, ASSj^AXT IX THE Df:PAKTMKXT OF URINARY 
DISEASES AT THE LARIBOISIERE IICaPITAL ; LAUREATE OF THE 
FACULTY OF THE ACADEMY OF MEDICINE. . 



TRANSLATED AND EDITED WITH ADDITIONS 

BY 

ABR. L. AVOLBARST, M.D., 

NEW YORK 

CYSTOSCOPIST, BETH ISRAEL HOSPITAL; CONSULTING UROLOGIST, CENTRAL ISLIP AND MANHATTAN 

STATE HOSPITALS ; GENITO-URINARY SURGEON, WEST SIDE GERMAN DISPENSARY AND 

HOSPITAL ; AUTHOR OF * ' GONORRHEA IN THE MALE, ' ' ETC. 



rVITH 217 FIGURES IN THE TEXT AND 24 CEEOMOTTrOGI^APniC PLATES OUT- 
SIDE THE TEXT, INCLUDING 76 DRAWINGS FPOM ORIGINAL WATER COLORS. 



ST. LOUIS 
C. A\ MOSBY COMPANY 

1918 






Copyright, 1918, By C. V. Mosby Company 






Press oi 

C. V. Mosby Company 

Sf. Louis 



PREFACE 



The iiii])()rtaiu'(' of ui-t'lJii-<-il ;iih1 vesical endoscopy is universally 
recognized. Physicians and surgeons are in constant need of the light 
shed by this science, which is one of the principal reasons for the 
existence of the modern urologist. But in order to apply the art skil- 
fully and thereby derive all the advantages it is able to offer, it is 
necessary to attain considerable practice and skill in urethroscopy 
and cystoscopy. 

Tlianks to the jDerfection of modern instruments, it is easy to 
obtain clear and distinct pictures; on the other hand, it is often dif- 
ficult to interpret the image which is presented, at first sight. For 
tliat reason, it is necessary to acquire considerable familiarity in j^rac- 
tical endoscopy, in order to attain that indispensable experience which 
gives one a mastery of the subject and the ability to make a correct 
diagnosis. 

This work is the result of fifteen years of practical endoscoi^y. 
Its object is to present to the medical profession the procedures and 
methods which have been so well perfected as to enable us to deter- 
mine the condition of the urethral and the bladder mucosa, and also 
of the ureters, pelves and kidneys. Its object is to meet the needs, not 
only of students, who must be guided gently step by step into this 
wonderful science, but also of those who, though quite familiar with 
the practice of cystoscop}" and urethroscopy, are not acquainted with 
all of its useful applications. Undoubtedly many urologists are thor- 
oughly acquainted with the ordinary urethroscopic an^l cystoscopic 
technic; nevertheless, there are but few who full>' realize all the ad- 
vantages that can be derived from the most recent progress in urothros- 
cop3^ and cystoscopy. 

It is the purpose of this work to illustrate and i)oi)ularize the 
science of direct vision cystoscoi)y and the marvelous ai)plications 
which it renders possible. The treatment of i)rostatic hypertr()i)liy 
endourethrally, the endovesical treatment of l)ladder tumors, the re- 
moval of foreign bodies from the bladder, and biopsy of the liladder, 
are just so many ccuupiests, as yet too little known, and Avhicli it is 
well to make known to the medical world. 

Since the onset of the present AVorld AVar, sclent ilic activity has 

9 



10 PREFACE 

diminished everywhere, owing to tlie more serious duties with which 
scientific men find themselves preoccupied. 

Doctor Wolbarst, of New York, who has undertaken to translate 
my work into English, and whom I have given sole authority, with 
the greatest pleasure, is perfectly qualified to do the subject justice: 
for the large experience which this well-known urologist has acquired 
in his specialty has fitted him perhaps better than anyone else to 
understand and interpret my work. 

It has been a great satisfaction to me to know that in the work 
that he has done he has almost always reached the same conclusions 
and found the same therapeutic indications as I have in my own 
practice. 

I am glad to state that this important translation which he has 
undertaken this year, has been brought up to date, and that the reader 
will find all the information necessary, not only as to the technic of 
cystoscopy and urethroscopy, but also in the therapeutic applications 
of these instruments. 

The book consists of six chapters. Urethral and vesical endos- 
copy are first studied historically and in a general way. This is fol- 
lowed by a chapter on urethroscopy proper, and another on the use of 
urethroscopy in catheterization of the ejaculatorj^ ducts and in the 
endoscopic treatment of prostatic hypertrophy. The remainder of the 
work, that is, its major portion, is devoted to the stud}^ of cystoscopy. 

Cystoscopy in general, jDrismatic (indirect) cystoscopy, and direct 
vision cystoscopy are considered, not so much from the instrumental 
standpoint, which would only constitute a tedious recital, as from the 
point of view of the practical results obtained with the use of these 
instruments. The chapter on the cystoscopic appearance of the nor- 
mal and pathologic bladder has been treated with special detail be- 
cause of its very great importance. Direct vision c^^stoscopy is de- 
scribed in all its details in the succeeding chapter. 

Further on, catheterization of the ureter w^ith its technic, its indi- 
cations, difficulties, and accidents is taken up fully; likewise the oppor- 
tunities offered by ureteral catheterization, such as the search for 
ureteral calculus, the treatment of renal colic, the exploration of the 
renal pelvis, the treatment of pyelitis by jDclvic lavage, also radiog- 
raphy and pyelography. 

The next chapter considers the practical applications of cystos- 
copy^; that is, the endovesical treatment of bladder tumors by gal- 
vanocauterization, the cold or hot snare, electrocoagulation, electrol- 
ysis and radium. 



PREFACE 11 

The hist cliaiotcr is devoted to tlie treatment of foreign bodies in 
llie l)laddor and of the cystitos. Tliere is also a consideration of the 
instrumental exploration of the lower end of the ureter and of vesical 
biopsy. 

Particular attention has been given to the illustrations. The 247 
illustrations in black together with the 24 colored plates appeal directly 
to the eye of the reader. In the study of endoscopy nothing is so im- 
l)ortant as to establish a clear, reliable picture in the mind's eye, so 
that the reader may remember it and be able to make a correct diag- 
nosis in cases occurring in his practice. 

AVith pleasure, I express to the publishers, Messrs. 0. Doin & Son, 
gratitude for the care they have exercised in the publication of this 
work; I also thank M. Dupret, draughtsman, for the consummate art, 
as well as the untiring patience, which he has been so good as to exhibit 
in the detailed endoscopic work which Avas entrusted to him. 

Georges Luys 

Paris, France. 

January, 1918 



TRANSLATOR'S PREFACE 



Tliis Irniislation of Tjiiys' woi-k on "Cyslosc()i)y and Uretliros- 
copy" was undertaken with a twofold purpose in view: First, to 
l)rini;' to American and other English-speaking urologists the message 
which Luys' book bears; and secondly, to express in concrete form 
the love and affection which the translator feels for France. 

This work was undertaken, in the first weeks of the great "World 
War, — weeks in which the fate of glorious France and the rest of the 
civilized world hung in the balance. And when, as if by a miracle, 
Paris was saved and the invader's progress arrested at her very 
gates, and all lovers of France breathed once more, it seemed to be a 
sacred duty and a pleasure, as well, to bring this fine book by one of 
her greatest urologists within easy reach of his confreres in America. 

Lu3^s' work is frankly a plea in behalf of direct vision cystoscopy 
and urethroscop3^ In America this method has not received the wide- 
spread and almost universal welcome that has been accorded the indi- 
rect method. Nevertheless, whatever the reason may be, it is felt that 
American urologists will w^elcome this thorough exposition of the direct 
method, so that they may at least compare it with the method with 
which they are more familiar. 

Several features stand out strikingly in contrast with usual works 
of this kind: First, the extensive and illuminating historical data, 
showing the origin and development of cystoscopy and urethroscopy; 
secondly, the discussion of topics that are not strictly urologic, but 
closely affiliated, such as the sections on uterine cancer and pregnancy. 

The translator has striven faithfully to transpose the author's 
lyric French into plain English, — frankly, a difficult task. There is 
always a fear of failure to express the author's exact meaning; but 
the effort has been made honestly, and it is hoped, successfully. Xo 
attempt has l)iH'n nuuh' to alter the tyineal French character of the 
work. Whatever additions or amendments have been made, have 
lieen inserted either for the purpose of bringing the subject matter uj) 
to the minute, as it were, or in order to make the subject more practical 
for American readers. 

I would take advantage of this oj)portunity to thank Dr. William 
E. Ciould, and my staff assistant. Dr. S. Steiner, for valuable assistanc(^ 

13 



14 translator's preface 

rendered in the translation; also Dr. William F, Braascli, of the Mayo 
Clinic, for his fine little article on "Direct Cystoscopy;" and lastl}'^, 
but by no means least, The C. V. Mosby Company, that has undertaken 
the publication of the translation in this inauspicious time of high 
cost of production, simply, to use its own words, as its ' ' contribution to 
France." It is a jDleasure, as well as a privilege, to subscribe to that 
sentiment. 

Abr, L. Wolbarst 

New York City 
May, 1918. 



CONTENTS 



PAOK 

Chapter I. — History ok Ukk/i'iikai, a.\d Vksical Endoscopy 25 

History of Eiidoscoj^y 25 

History of Urethroscopy 27 

Urethroscopes with External Ilhimination 27 

Urethroscopes with Internal Illumination 36 

Luys' Urethroscope 43 

Urethroscopes for the Posterior Uretlira 47 

History of Cystoscopy 54 

History of Direct Vision Cystoscopy 50 

Chapter II. — Urethroscopy 65 

Technic of Urethroscopy 70 

Contraindications to Urethroscopy 81 

Urethroscopy of the Normal Urethra 82 

Urethroscopy of the Pathologic Urethra 88 

Urethroscopy in the Female 110 

Chapter III. — Practical Application of Urethroscopy 115 

Catheterization of the Ejaculatory Ducts 115 

Eiidourethral Treatment of Prostatic Hypertrophy 135 

Chapter IV. — Cystoscopy 139 

.Anatomic Considerations 147 

Ureteral Meatotomy 150 

Ureteral Ejaculation 158 

Errors in Cystoscopy 162 

Dangers of Cystoscopy : 105 

Vesical Phantoms 167 

Chai'ter V. — PmsMATic (iKDUtEcr Vision) Cystoscopy IfiS 

Nitze 's Cystoscope 168 

Modification of Nitze 's Cystoscope 172 

Technic of Indirect Vision Cystoscopy ISl 

Diflficulties of Indirect Vision Cystoscopy 189 

Normal Bladder as Viewed through the IiKliicd X'isimi Cystoscojie 198 

Pathologic Bladder as Viewed tlirougli tlie liidiiect \'isi(iu ('yst()S(M)|H' 199 

Acute Cystitis 199 

Chronic Cystitis 200 

Cystoscopy in Tumors of the BhuliiiT 205 

Cystoscopy in Anomalies of the Biaddci- 20() 

Cystoscopy in Cancer of the Uterus 207 

Cj'stoscopy in the Cancerous Biaddci- 20S 

15 



16 CONTENTS 

PAGE 

Chapter VI. — Direct Vision Cystoscopy 218 

Conditions Necessary for Direct Vision Cystoscopy . 218 

Description of Luys' Direct Vision Cystoseope 225 

Teclmic of Direct Vision Cystoscoiay 229 

Advantages of Direct Vision Cystoscopy in Examination of the Bladder 234 

Objections to Direct Vision Cystoscopy 242 

Comparative Eole of Indirect and Direct Vision Cystoscopy . . . 243 

Direct Vision Cystoscopy During Pregnancy 248 

Chapter VII. — Catheterization of the Ureters 254 

Ureteral Catheterization with the Indirect Vision Cystoseope 254 

Technic of Ureteral Catheterization with the Indirect Cystoseope 263 

Ureteral Catheterization with the Direct Vision Cystoseope 267 

Technic of Ureteral Catheterization with Luys' Cystoseope 269 

Choice of Method in Ureteral Catheterization 285 

Indications for Direct Cystoscopy in Ureteral Catheterization 285 

Indications for Indirect Cystoscopy in Ureteral Catheterization 290 

Difficulties, Accidents, and Errors in Ureteral Catheterization 291 

Accidents Associated with Ureteral Catheterization 293 

Errors Associated with Ureteral Catheterization 298 

Ureteral Catheterization in Children 306 

Chapter VIII. — Information Derived through Ureteral Catheterization .... 307 

Exploration of the Ureter 307 

Detection of Ureteral Calculi 307 

Treatment of Nephritic Colic 312 

Exploration of the Eenal Pelvis 313 

Ureteral Catheterization in Kidney Function Tests 319 

Treatment of Pyelitis by Pelvic Lavage 320 

Ureteral Catheterization — a Demeure 324 

Radiography of the Ureteral Catheter 326 

Pyelography 326 

Chapter IX. — Practical Applications of Cystoscopy 329 

Treatment of Bladder Tumors 329 

Endovesical Treatment of Bladder Tumors 330 

Galvanocauterization 330 

Nitzc's Method 331 

With the Direct Vision Cystoseope 332 

Technic of the Endovesical Treatment of Bladder Tumors with Luys' Operating 

Cystoseope 333 

Treatment of Bladder Tumors with the Cold or Hot Snare 342 

Electrocoagulation of Tumors of the Bladder 347 

Endovesical Treatment of Bladder Tumors by Electrolysis 354 

Endovesical Treatment of Bladder Tumors by Radium 355 

Chapter X. — Treatment of Foreign Bodies in the Bladder 357 

Actual Foreign Bodies 357 

Treatment of Vesical Calculi 354 

Treatment of Cystitis 374 

Instrumental Exploration of the Inferior Extremity of the Ureter 374 

Vesical Biopsy 37g 



ILLUSTRATIONS 



kk;. pack 

1. T)('s()iitu';uix 's ur('tlni>s('()]u> • 27 

'2. Iliir1('|(ni|i 's iii('11ii(iscu|i(' 28 

'A. Lc'ilci 's paiiclcctioscopc 28 

4. Scluitzo'.s (lia])hotoseo]ie 29 

5. Xyrops' oleftrnuiotliioscopo 20 

(). Laiiy 's iii'('tlirosc()|)o 29 

7. Otis' uioHnoscope ."^O 

S. Casper's electroscope ^'>0 

9. Antal's aorouretliroscope •"''1 

1 (). Fenwick 's aerourethroscope 32 

n. Clar's photophore 33 

12. Urethroscopie tul)e and its iil)turator 33 

13. Griinfeld's tul)(^ witli wimlow and iiiiri'or 34 

14. Horteloup's bivalve speculum 34 

15. Kollmann-Wiehe tubes 35 

Ki. Nitze's urethroscope 37 

17. Oberlaender's urethioscope 37 

18. Valentine's urethroscopie lamp 38 

19. Valentine 's lamp carrier 38 

20. Oberlaeuder-Kollmann urethroscopie tube 38 

21. Valentine's urethroscopie outfit 39 

22. Kollmaun's photographic urethroscope 39 

23. Handle of Kollmann-Wiehe 'a urethroscope, provided willi an dptic ap[iaratus ... 40 

24. Wasserthal 's aerourethroscope 40 

25. Gordon's endoscope 41 

2G. Handle and telescope of Kaufmann's uretlirosco|)e 41 

27. Luys' long cystoscopie tulie and its obturator 43 

28. Luys' short urethroscopie tulie and its lamp 43 

29. Handle of Luys' urethroscope 45 

.'!0. Improved model of the handle of Luys' uretludscojie 45 

31. Profile view of Luys' urethroscope ( complete ) 40 

32. Illustrating liow the prominence of tlie veramontanum aiK^sts aiul nbstrucls tiu^ ex- 

tremity of the urethroscopie tube 47 

33. Le Fiir's urethroscopie lamp 48 

34. Le Fiir's uretlu'oscope 48 

'.)'). (ioldschmidt 's j^osterior urethioscope 48 

.">(). (ioldschmidt 's anteiior urethroscope 49 

37. Buerger's cystoui('throsco])e 50 

38. Wossidlo's posteiior urethroscope . . * 51 

;i9. Kelly's cndo.-coiiir tulie 57 

4(1. Mcthoil of liolding Kelly's endnscoiiic tube 57 

41. I'awlicU's eiidosco|ii(' tulic :inil ohluratoi- 58 

42. Ptiwlick's endoscope with its lam|i and ii'rigaliiig a|i|iaiatns 58 

4.'!. Gaireau's endoscopic tube with its uiin<' asiiiralor 59 

-14. ('ulli'ii's cysloscope GO 

17 



18 ILLUSTRATIONS 

FIG. ** PAGE 

45. Urethroscopie examining table (author's model) 71 

4G. Rheostat for light and cautery adapted for city cun-ent 72 

47. Rheostat for light and cautery, using city current 72 

48. Rheostat for light, using city current 73 

49. Light controller 73 

50. Pocket battery . . " 73 

51. Sigurta's portable battery for electric illumination 74 

52. Wooden cotton carrier 74 

53. Special forceps for intraurethral work ■ 74 

54. Examination of the anterior urethra 75 

55. Examination of the posterior urethra .75 

56. Ten cubic centimeter syringe . 76 

57. Introduction of the urethroscopie tube into the posterior urethra •. 76 

58. The Urethroscopie tube having been introduced, the obturator is withdrawn and the 

handle is attached to the collar of the tube (lamp pointing downward) ... 77 

59. In the examination of the posterior urethra, the' handle of the urethroscope is turned 

upward, the lamp also upward 78 

60. Intraurethral manipulation; drying the mucosa with cotton swabs ....... 79 

61. Urethroscopie view of the "prostatic fossette" 85 

62. Anatomic view of the "prostatic fossette," comprised Ijotween the posterior margin 

of the verumontanum and the bladder neck 85 

63. Normal verumontanum, the orifice of the prostatic utricle not visible 86 

64. Normal verumontanum, the orifice of the prostatic utricle visible 86 

65. Normal verumontanum, without a median prostatic utricle , 87 

66. Kollmann's pipette, for aspirating the glandular secretions 90 

67. Little polypus situated at the bottom of a lacuna of Morgagni 91 

68. Urethroscopie lesions of the prostatic fossette, behind the verumontanum .... 101 

69. Glandular lesions of the anterior surface of the prostate, seen with the urethroscope . 102 

70. Polypus on the summit of the verumontanum 107 

71. Long eel-shaped polypus on the anterior aspect of the verumontanum ...... 107 

72. Long phallus-shaped polypus on the superior aspect of the verumontanum . . . . 108 

73. Hypertrophied verumontanum, the result of a chronic inflammation 110 

74. Luys' direct vision cystoscope, female model, complete . Ill 

75. Large pediculated polypus in the female urethra __ 112 

76. Classic arrangement of the ejaculatory canals 116 

77. Verumontanum without any visible orifice 117 

78. Ejaculatory canals opening on the lips of the prostatic utricle 117 

79. No prostatic utricle visible; the ejaculatory canals open on the lateral walls of the 

verumontanum, resembling a diver's helmet 118 

80. The ejaculatory canals open on the lateral walls of the verumontanum but at dif- 

ferent levels lis 

81. Urethroscopie view in which the prostatic utricle is visible 119 

82. The ejaculatory canals made visible only after incision of the utricle 119 

83. Gun-barrel aspect of the ejaculatory canals 120 

84. A stylet introduced into the orifice ' of the ejaculatory canals, enters the seminal 

vesicles, and not the vas deferens ■ 123 

85. ''Vesicular casts," obtained by massage of the seminal vesicles 123 

86. Metallic bougies for catheterization of the ejaculatory canals 130 

87. Star-shaped cicatrix resulting from a perforation of the bladder, due to an abscess 

of the right iliac fossa I43 

88. View of a vesical perforation of an adjacent abscess I44 

89. The floor of the bladder '.'.'.'. 148 

90. Normal ureteral orifice projecting like a papilla I5I 



TTJJJSTRATTONS 1^ 

PIG. PACK 

ill. XiiiiiNil iii'clci'il iiiilii-i' ill llir sliii|i(' III' ;iii iilili(|ii(' clcCt 151 

ill'. L:ii-f, (i[i(Mi inclcrnl orilirc 151 

il.'l. rictt'i'iil (uKicc sliiipcil liUc llu' licak of v. claiiniicl tc . 151 

!t4. Uiclcral orifice IciigtlKMicd into ;i sliar|i line 151 

!t5. NiiTiow ui'Ptoral orifice with thiclveiicil lips, iiulii-iitixi' nt' :i inilij pvclilis .... 151 

9(5. Arch-sluipcd orifice indicative of a ureteral dilatation 151 

07. Golf-hole-shaped lU'eteral orifice, indicatin<i' a destruction n\' llic l;idiicy, as ohscrved 

in renal calculus and tuberculosis 151 

its. Retraction of tlie uretei-al oiifice, tlie result (if an iiiliaiiiiiiat idii uT tlic uietei' . . . 15-1 

ilii. I'loJajise iii' tiic iiiwcr c.xl iciiiity (if the li^lit ureter 155 

liHI. I'lolapse of llie iiicler, witli ureleial i-aleiijiis, ami eiipped liy a secundaiy vesical 

calculus 15t! 

lol. Auonuily of the ureteral orifices 157 

10:2. Anomaly of the ureteral orifices 157 

103. Ejaculation of thick pus, like a wliirlpool, from a ureteral orifice 161 

104-. Ejaculation of pus from a ureteral orifice as from a tidic of jiaint 162 

105. Bladder phantom 166 

10(). Nitze's cystoscope 169 

107. Sectional view of Nitze's cystoscope 169 

108. Optical system of Nitze's cystoscope 169 

10i». C}'stoscoj)e lamp and its mounting 170 

110. Ordinary attachment of the indirect cystoscope 171 

111. E. Frank's improved attachment for the indirect cystoscope 171 

112. Course of the light rays in the Nitze-Frank cystoscope 172 

11.1. Cystoscopic image in the early cystoscopes (inverted) 173 

114. Cystoscopic image corrected in Frank's new cystoscope 173 

115. Course of the light rays in a cystoscope, with Ringleb's system 173 

116. Amici's prism, in the form of a housetop 174 

117. Brenner's cystoscope 174 

118. Automatic valve, in irrigating cystoscopes 177 

119. Schlagintweit's cystoscope 178 

120. Kutner 's demonstration cystoscope 178 

121. Sectional view of Kutner 's cystoscope 178 

122. Jacoby's corrective mounting .^ 179 

123. Kollmann's photographic cystoscope 180 

124. Formaldehyde sterilizer 181 

125. Indirect (prismatic) cystoscopy; position of operator and jiatient 183 

126. Application of the indirect cystoscope 184 

127. First step in the introduction of the indirect cystoscope 185 

128. Second step in the introduction of the indirect cystoscope 185 

129. Third step in the introduction of the indirect cystoscope 187 

130. Fourth step in the introduction of the indirect cystosco|)e 187 

131. Faulty introduction of the cystoscope 192 

132. Large visual field of Nitze's cystoscope 194 

133. Schematic representation of the reflection of an iiHai;e in a jilane mirror .... 195 

134. Schematic representation of Nitze's systojn 195 

135. Same as Fig. 134 195 

136. Same as Fig. 134 ■ 196 

137. Same as Fig. 134 196 

138. Genupeetoral position adojited by Kelly for endoscopic examination in the male . . 220 

139. Metliod of introduction of Kelly's endoscopic tube in the male 220 

140. Position of female organs in the inclined position 221 

141. Position of female organs in the genujiectoral position 221 



20 ILLUSTEATIOlSrS 

FIG. PAGE 

142. First stei^ in the examination of the blaflcler in the genupectoral position in tlie male 222 

143. Local treatment of cystitis in the male, in the genupectoral position 223 

144. Water horn (faucet) 224 

145. Luys' female cystoseope, with its straight oljturator 224 

146. Luys' male cystoseope, with its ell)()we(l obturator 224 

147. Handle of the direct vision cystoseope, with its movable lens 225 

14S. Collin's group of batteries 226 

140. Luys' direct vision cystoseope for the female 226 

150. Luys' direct vision cystoseope for the male 227 

151. Tampon of cotton mounted on a wooden applicator 229 

152. Table specially built for urinary examination, horizontal position 229 

153. Table specially built for examination with direct vision cystoseope . . . . . . 230 

154. Examination of the bladder with the direct vision cystoseope 231 

155. Examination of the bladder 232 

156. Assistant elevating the abdominal wall 233 

157. Vesicovaginal fistula 237 

158. Determining the exact position of the orifice of a fistula by means of direct vision 

cystoscoijy 238 

159. Diagram showing the arrangement of the ureterovesicovaginal fistula 239 

160. Diagrammatic section showing the aspect of the bladder in pregnancy 248 

161. Frozen section of a j)regnant female 249 

162. Aspect of the bladder in a frozen section of a j^iegiiant female 250 

163. View of the bladder and ureteral orifices in the pregnant female 252 

164. Mtze's cystoseope for ureteral catheterization; improved model 256 

165. Casper's ureteral cystoseope 256 

166. Casper's double ureteral cystoseope 256 

167. Albarran's simple cystoseope 257 

168. Albarran's cystoseope provided with its ureteral attachment 257 

169. Albarran's deflector ' . 257 

170. Bierhoff's modification of Albarran's cystoseope 259 

171. Freudenberg 's cystoseope for catheterization of both ureters 260 

172. External tube of Freudenberg 's cystoseope 260 

173. Optical portion (telescope) of Freudenberg 's cystoseope 260 

174. Irrigating tube of Freudenberg's cystoseope 261 

175. Ureteral catheter guides for Freudenberg's cystoseope 261 

176. Cross section of Freudenberg's cystoseope 261 

177. Position of the cystoseope and the hands in catheterizing the left ureter .... 263 
1 78. Position of the cystoseope and the hands in catheterizing the right ureter .... 264 

179. Ureteral catheter in favorable position for easy entrance into the ureteral orifice . 265 

180. Ureteral catheter in poor position 265 

181. The ureteral catheter having entered the right ureter 265 

182. The ureteral catheter having entered the left ureter 265 

183. Pawlick's ureteral catheters 268 

184. Kelly's ureteral explorer 268 

185. Finding the ureteral orifices with Luys' direct vision cystoseope 271 

186. View of the left ureteral orifice magnified by the lens of Luys' direct vision 

cystoseope 272 

187. Direct catheterization of the left ureter 273 

188. Small catheter provided with a metallic stylet for direct catheterization of the 

ureter in the female 274 

189. Ureteral catheter devised especially for direct catheterization of the ureter . . . 274 

190. Direct ureteral catheterization in the male 275 

191. Enormous distention of the renal pelvis 278 



.LCSTKATIONS 



21 



|,|,;. PAWE 

liil!. I'rctcr.-il cat licl ri' within a iiictcr 302 

l!).".. Nit/.o's luetoial catlictois will: iloiiMi' canals .''.OP. 

1!I4. Wax-tii)]icil cathotors lioaiin^ llic si-raldi inaiks dT a <-alculus HOS 

111.-,. TivUMal calruli -".OO 

I'.K). Calculous py()iie|)lir().sis (cxtrnial a.-^in'cl j -'.Ifi 

If) 7. Calculous pyonephrosis 317 

Tits. Conf.eiiitalliyclronephro.sis rrsultiu^- in an aluhiniinal renal lislnla 325 

iilO. Nitzo's operating- cy.stnseo|u' . . 331 

lidO. l)(_'striU'tioii by Inirninfj of a bladder tunioi tliroii-h the natuial |ia.ssages .... 334 

'2i)\. \'esical papilloma; microscopic soctiou 338 

L.'iil!. i'liiin's (i]ierating cystoscope 343 

:Jll."). Cuitent transformer for electroc(.>aL;'ul:itinn 348 

li04. View of a bladder tumor situated in median line nf the trijione 351 

-05. 8ami> as Fig. 204. First application of electroco;iuulation 351 

•200. Same as Fig. 204. Eight days after the application of el(>c1 rocnagulatiou . . . 352 

'207. Same as Fig. 204. Second application of electrocoagulation 352 

20S. Same as Fig. 204. Fifteen days after the application of electrocoagulation . . . 353 

209. Celluloid hairpin, after having lain in the bladder nine days 359 

210. Forceps for the extraction of foreign bodies through the direct vision cystoscope . o59 

211. Fragment of a Pezzer catheter, broken off in the bladder 360 

2] 2. View of the bladder mucosa in bullous cystitis 362 

21.'". Thti'e strands of silk thread the ends of which, project into the bladder .... 363 

214. Three additional strands of thread, with a knot projecting into the bladder . . . 363 

215. View of a phosphatic calculus seen through Luys' direct vision cystoscope . . . .365 

216. Extraction of a phosphatic calculus through Luys' direct vision cystoscope . . . 367 

217. Silver nitrate stick for endovesical cauterization 373 



COLOR PLATES 



l>LATK PAGE 

I. The verumoutiimim 5L 

II. Eel-shaped and phallus-shaped polvpi on tlic vcnmioiitaiiimi 66 

III. Glandular lesions of the uictliia and prostate 89 

IV. Pathologic lesions on the verumontanum and prostate 92 

V. Lesions of the verumontanum; also showing the ejaculatory ducts 104 

VI. Prostatic cavern in chronic prostatitis ; urethroscopic view of a urethral stricture 122 

VII. Endoscopic views of the anterior urethra 132 

VIII. Pathologic lesions of the male urethra ; enormous polypus of the female urethra . 146 

IX. Papillomatous tumor of the bladder 160 

X. Normal and pathologic views of the bladder 176 

XL Silk thread in the bladder; syphilis of the bladder 188 

XII. Normal and pathologic views of the bladder and ureters 202 

XIII. Normal ureteral orifice; same in pregnancy; ureteral emission; trabeculatcd 

bladder; urethrovesicovaginal fistula 214 

XIV. Chronic cystitis; vesical herpes 228 

XV. Vesical leucoplakia; cluonic cystitis 240 

XVI. Tubei'culous ureteral orifice and vesical ulcerations 258 

XVII. Polypi on the vesical neck 270 

XVIII. Phosphatie vesical calculi; tul)erculous vesical ulcerations 284 

XrX. Cancerous tumors of the bladder 300 

XX. Inflammation and localized abscess of the vesical neck 310 

XXI. Bullous edema of the vesical fundus 322 

XXIL Tumor of the roof of the vesical neck ; vesical fistula 336 

XXIII. Edema of the ureteral orifice 344 

XXIV. Vesical tumor; vesical cancer; bullous edema; purulent ureteral ejaculation . . 358 



CVSTOSCOI^Y AND Uin:rHliM)SC()PV 



CHAPTER I 
liiSTUliY OF UliETHRAL AND M^:hICAL ENDOSCOPY 

HISTORY OF ENDOSCOPY 

Ever since ancient times, physicians liave made efforts to inspect 
the natural ca^T.ties of the body mth special instruments. Even 
aniono- the ancient Hebrews^ the use of the vaginal speculum was 
alread}' known; and in the surgical arsenal which was discovered in 
the excavations at Pompeii, instruments designed for the exploration 
of the rectum were found. Naturally, instrumental examination could 
I)e made only of the large body cavities which are easy of access, such as 
the mouth, vagina, and rectum. Efforts to penetrate a ca^^ty A\itli a 
hmien as narrow as that of the urethra or the bladder, were in vain, and 
tlie first solutions of this difficult problem l^egan to show themselves 
only as we approach modern times. 

Historically considered, it appears tliat endoscopy only goes as 
far back as the beginning of tlie nineteenth century, and it was Bozzini, 
of Frankfort, who in 1805 was the first to attempt the direct inspection 
of the cavities of the body. He constructed tubes of different shapes 
and lengths, chiefly for the study of the urethra. To illuminate the 
interior of his tubes, lie ('mi)loyed reflected light; but this form of 
iiisti'umentation was certainly too primitive and defective, and bis 
ffuitless efforts wei-e quickly forgotten. Similar efforts of Fisher, 
of Boston, in 1824, met with (Mpial lack of success. 

Later, in 1826, Segalas- presented to the Academy of Sciences of 
X^aris a urethrocystic speculum, designed for tlie examination of the 
urethra and bladder. This, too, Avas soon foi-uotten. He employed 
two coneenti-ic metal tubes, the innei' perniilting a \ie\v of the blad- 
der while the outer allowed the light from two candK's to enter, th'- 
light being i-eflected by a concave mirror. 

The real beginnings of endoscopy wei-e made, however, in France, 
and should be put to the ci-edit of Desormeaux. who in 1853, was the 

25 



26 CYSTOSCOPY Al^B URETHROSCOPY 

first to examine the uretliral and vesical mucosa in the living subject 
through an endoscopic tuhe in the urethra. The works of this author 
actually establish the beginning of endoscopic study, and he fully de- 
serves the title of "Father of Endoscopy" which has been bestowed 
on him. He was fully justified, too, in writing on the covers of his 
treatise on endoscopy, this cry of triumph: ''Nos quoque oculos erudi- 
tos habemus." (Cic). 

In 1865 he published an important work in which he made public 
the results of his experience.' Desormeaux's instrument consisted of 
a series of tubes of different calibers and lengths which were introduced 
into the urethra. The source of light was a petroleum lamp; the 
illumination was brought into the interior of the tube by a reflecting 
mirror pierced in its center and inclined to an angle of 45 degrees to 
the tube. This apparatus was based on the same principle as that 
of Bozzini. 

Desormeaux's endoscopic researches became well laioA^m and at- 
tracted the attention of other investigators to such an extent that under 
this stimulus, similar efforts were soon multiplied in number ; the first 
that appeared were those of Hacken* in 1862, and of Cruise' in 1865. 

At that time, the principal aim was to increase the intensit}^ of the 
light, in order to illuminate the lower end of the endoscopic tubes. 
AYith this object in mind, Furstenheim, of Berlin,^ substituted gas for 
the petroleum light, and Andrews,^ in 1867, and later Stein^ employed 
a magnesium light. 

Up to the time of Desormeaux, all the attempts to inspect the 
urethra and the bladder may be considered together; since his time, 
however, a clear difference must be established between those who de- 
voted themselves especially to the studv of the urethral mucosa and 
those who attempted to inspect the bladder particularly. It is there- 
fore proper to make a separate study of the history of urethroscopy^ 
as distinguished from that of cystoscopy. 

REPEEEISJ'CES 

iKasenelsolin : Die aSTormale imd Pathologisehe anatomie des Talmua, in Eoberts' Historische 
studien aus dem Pharmakolgisclien Institute zu Dorpat, 1896, v, p. 276. 

2Segalas: Trans. Acad. Sc, 1826. Traite des retentions d 'urine, Paris, 1828. 

sDesormeaux: De 1 'endoscopic et de ses applications au diagnostic et au traitement des 
maladies de I'uretre at de la vessie, Paris, 1865. 

*Hacken: Dilatatorium urethrge zur Urethroscopie, Wien. nied. Wchnschr., No. 12, 1862. 

sCruise: The Utility of tlie Endoscope, Dublin, Quart. Jour. Med. Sc, May, 1865. 

ePurstenlieim: Berl. klin. Wchuschr., 1870, Nos. 3 and 4j Oesterreich Zeitschr. fiir Jahresb. 
Heilkr., No. 25, 1870. 

^Andrews: The Urethra Viewed by Magnesium Light, Med. Eec, New York, 1867, ii, p. 107. 

sStein: Das Photoendoscop, Berl. klin. Wchnschr., 1874, No. 3. 



HISTORY OF URETHROSCOPY 



27 



HISTORY OF URETHROSCOPY 

Numerous models of Tirctliroscopes have already been suggested, 
and allliougli ilic list ol' existing iiistruinciits is a long one, it is still far 
from complete, and avo nmst expect new ones to appear continually. AVe 
may classify all existing uretliroscopes into two quite distinct gi'oups: 
1. Urethroscopes with external illumination; that is, whose source of 
light is situated outside of the urethroscopic tuhe. 2. Urethroscopes 
with internal illumination; that is, with tlie source of light situated 
inside of the tuhe. 

Urethroscopes with External Illumination 

This group itself comjjrises two distinct types of instruments: 

1. Those in which the source of light is attached to the urethroscope. 

2. Those in Avhich the light is independent of the urethroscopic tuhe. 

1. Urethroscopes With External Illumination Attached to the 
Urethroscopic Tube. — The first apparatus of this kind was constructed 
by Desormeaux, the originator of. the method. Fig. 1 is self-explana- 
tory. This j)rimitive urethroscope was soon improved upon, for the 




Fig. 1. — Desonneaux's urethroscope. 



illumination A\'hich was furnished by an oil lamp and later by a petro- 
leum lamp, was quite insufficient for its purpose. The electric light 
eventually gave to this method of examhiation the position it deserves. 
This important im])rovement to Desormeaux's urethroscope was con- 
tributed by Horteloup (Fig. 2). 

In this 'same group of instruments nmst also be mentioned the 
following : 

(a) The panelectroscope of Leiter (Fig. 3). This instiiunent con- 
sists of tubes of varying calibers and lengths, corresponding to No. 



28 



CYSTOSCOPY AND URETHEOSCOPY 



18 or No. 20 Cliarriere, which are introdnced into the urethra by 
tlie aid of an obturator or stylet. Illumination is furnished by an 
electric lamp (B), placed in a semicylinder open on its upper sur- 




Fig. 2. — Horteloup's urethroscope. The cyl- 
inder containing the lamp is closed; there is 
a concave mirror at ^; at C a strong lens in- 
creases the intensity of the light which is 
reflected upon an inclined mirror F, thence 
carried into the speculums, which are held to- 
gether by a metal ferrule E ; at the extremity 
of the telescope D, is a group of lenses. 







face; the light is thrown upon the mirror (D), and thence reflected into 
the urethroscopic tube (A). A lens (C), which can be adjusted accord- 
ing to one's vision, magnifies the field, in order that one may see more 




^ 



Fig. 3. — Leiter's panelectroscope.^ — It is open above; 
the light is reflected upon the mirror D, into the specu- 
lum A; a lens C, magnifies the image. 



clearly at the distal end of the tube. This instrument has been again 
taken up by Heitz-Boyer, who presented it to the Surgical Society.^ 



HI.STORY OV IMtlCTIIltOSCOPY 



29 






Fig. 4. — Schutze's diaphotoscope. 





Fig. 6. — Lang's urethroscope. 



30 



CYSTOSCOPY AITD URETHROSCOPY 



'V\w only important niodiiication wliicli lias been made consists in the 
illuinination whicli is similar to that which Brnnning has applied re- 
('(•iil!\- to the csophagoscope. 




Fig. 7. — Otis' urethroscope. 



This instrument is open to the same criticisms which may he 
directed against all nrethroscopic instrmiients having external illmni- 
nation (see page 35). An attempt based on the same plan was made 
recently by Wyndham Powell,^ who constructed a urethroscope with 




Fig. 8. — Casper's electroscope. 



external illumination which provided parallel rays of light. With this 

instrument, examination of the urethral mucosa requires air dilatation. 

Horteloup' gave up the use of Leiter's panelectroscope because of 



niSTOFiV OF ri;i:Tiii;os('r)Tv 



31 



lis iii('()ii\-('iiiGnces aiKi rciiiiiKMi i 
iiK'niix, iiii[)i'OVOcl ^\'\\\\ ;iii elect lic 

())) The diaplioioscoix' of Scliulzc, (Fi^-. 4). 

((0 Tlio electroiirotliT()S('()i)o of Nyi'0})s ( Kii;'. r) 

(d) TliG urethroscope of Lang (Fig. G). 

(o) Tlie uvotliroseope of Otis (Fig. 7). 

(f) ^Hic electroscope of Casix-r (Fig. S). 



he |illlllil i\ I' Ill>1 lllllielil of I )<'sor 

111). 




Fig. 9. — Antal's aerourethroscopc 



(g) The aerourethroscope of Aiital (Fig. 9). Thi.s instruiiu'iit 
contributed another iniprovenient. It Avas designed to separati' and 
distend the urethral walls to their iiiaxiiiiiim exleiil. 1'lie invthroscopic 
tube is closed at its proximal end by a movable AviiuU)\v acting like a 
valve, which permits air to be forced into the canal of the urethra by 
means of a bulb. During the examination, the window retains the air 
ill the tube, without interfering witli vision in tlie least: meanwliile nii 



32 CYSTOSCOPY AXD UEETHKOSCOPY 

assistant makes pressure on the urethra either at the level of the 
)„Min.'iiin ()!• at the membrauons urethra through the rectum. By this 
,n..11i,.<l 111." uretliral walls are separated by the pressure of tli^ air, and 




Fig. 10. — Fenwick's aerourethroscope. 

can be examined over an area of several centimeters. Femvick, of 
London, modified this instrument (Fig. 10). 

EEFEREK'CES 

iBull. de la Soc. de Chirurgie, Jan. 4, 1911, p. 38. 

^Lancet, London, May 2-1, 1913, p. 1463. 

■'•Hovtoloup: Uretrite dironique, Paris, Massou, 1892, p. 43. 

2. Urethroscopes with External Illumination Independent of the 
Urethroscopic Tube. — Griinfeld, of Vienna, originated this method in 
1881. He introduced a tube into the urethra and with the aid of a 
reflector, he projected rays of light into its lumen. This reflector, 
pierced Avith an aperture in its center, permitted the observer to ex- 
amine the urethral mucosa. As a source of illumination, he used either 
the sun's rays, diffused daylight, the light of an oil lamp or gas, or 
finally, an electric lamp. The reflector was either supiDorted by a 
handle held in the hand, or what was more practical, affixed to the 
forehead of the observer by a headband. 

Clar's photophore (Fig. 11) constitutes a decided improvement 
on tlie frontal mirror of Giiinfeld. It consists principally of an elec- 



JTisTr)nv OF rnr/nrnosropv 



33 



trie lain]) pliiccd in the cciitci' of a convex miiror wliidi is allacln'd lo 
the forcliead by a lu'a(ll)aH<l. 

Tlio Tirotliroscopic tubes wliicli (iriinrdd ('m))l<)y('d \v('i-<' cither 
straight (Fig-. 12) or ciii-vcd. lie also u^ini stiaight tulx-s with win- 
dows provided witli a jcflecting niiiroi- ( Fcnstcrspiogclondoscop), Fig. 
ll). Tliis iiistniincnt consisted ol' an oi(linar>- metallic tube in the 




Fig. 11. — Clar's photophore. 

lateral wall of which was an opening of V/2 to 2 centiineters, covered 
with a little glass window. The urethral extremity of tlie tube Avas 
closed with a metallic tip, to which was attached a little minor at an 
angle of 45 degrees. The light rays which penetrated into the tube 
were reflected by this mirror upon the lateral window of the tube and 
the operator Avas enabled in this way to make an examination of the 
urethral walls. 

Urethroscopic tubes have been modified since by numerous authoi-s. 




Fig. 12. — Urethroscopic tube and its obturator. 

Posner has recommended glass tubes varnished l)lack inside, to i)i-evfnt 
the reflected ligiit in the tube from dazzling the observer. Tulx's of gum 
and hard rubber have also been reconmiended. 

AVith the object of enlarging the field of vision, Ausi)itz devised a 
urethroscopic tube with two movable valves opening into the urethra, 
so as to obtain the maximum view of the urethral nuu-osa witiiout at 



34 



CYSTOSCOPY AND URETHROSCOPY 



the same time dilating the urinary meatus. This idea has also been 
utihzed by Oberlaender and by Horteloup (Fig. 14). By separating 
the arms of the tube by means of the screw D, the field of examination 
in the urethra is increased. 

Finally, Janet suggested a double endoscopic tube. It is composed 
of two tubes, one sliding into the other. The inner tube has a Avindow 




Fig. ;13. — Griinfeld's tube with window and mirror. 

which permits inspection of the bladder neck. The outer is an ordinary 
urethroscopic tube open at both extremities. When the inner tube is 
removed, the outer enables the observer to examine the urethra in the 
usual manner. 

Quite recently tubes have been constructed according to the sug- 
gestions of Kollmann and Wiehe (Fig. 15). ' Their object is to permit 




(^ 




Fig. 14. — Horteloup's bivalve speculum. By removing the branches, by means of the screw D, the vis- 
ual field at the bottom of the urethra is increased. 

the dilatation of the distal portion of the tube by means of a screw 
situated at its outer extremity, in a manner similar to the dilatation 
of the horn of a bagpipe. But this method, while very ingenious, really 
gives but a very slight enlargement of the visual field and the slight 
advantages which are thus secured hardly compensate for the incon- 
veniences of the method which are due to its complexity. 



n I STORY OF URETHROSCOPY 



35 



Advantages and Disadvantages of Urethroscopes Having Exter- 
nal Illumination. — Tlie oulstandin^' advaiila^'c of iii-elliroscojH's willi 
external illumination is that manipulation or iiilcrveiitioii in the in- 
terior of the tuhe is simplified. The cotton carrier- and the instruments 
Avhicli are introduced into the tube are freely nioval)le and do not 
interfere with the source of light. Besides, the field of vision is cei-- 
tainly somewhat greater than in the case of internally ilhiiiiiiia1<Ml 
urethroscopes, in which the lamp occuioies a certain amount of tlie 
lumen of the tube. 

But these advantages are not without some very serious incon- 
veniences. Principal among these is the fact that they do not iirovide 
a clear and distinct view. However intense the light may be, it is 
always too feeble just where it ought to be strongest; namely, at the 
bottom of the tube. Inasmuch as we approach the source of light as 
closely as possible when we desire to see an object well, there is a 




Fig. IS. — Kollmann-Wiehe tubes. 

similar reason for placing the illumination as near as possible to tlic 
urethral mucosa. We may, therefore, conclude that internal illumina- 
tion will always lorove superior to external illumination.^ 

In order to convince myself of this fact, I have made a series of 
experimental comparisons. Holding a simple tube vertically, I tirst 
projected into it the rays of a very powerful electric light, situated 
outside the tube and obtained but a fairl}^ good view at the bottom of 
the tube. On the other hand, when I substituted for the external 
illumination a very small lamp placed directly at the point of examina- 
tion, I obtained a splendid illumination and a nmch more distinct vicAv 
than previously. It Avas indeed natural to expect that this method 
would furnish a light superior to that obtained by external illnmi na- 
tion. Bringing the light as closely as possible to the area to be exam- 
ined is by far the most favorable condition for obtaining a satisfactory 
view. A beacon light, be it ever so powerful, if situatcnl at some dis- 
tance from the surface to ])e examined, will give less illumination tlian 
a simple electric light placed directly over it. For these reasons, I 



36 CYSTOSCOPY AND URETHEOSCOPY 

think it is exercising good judgment to give preterence to uretnro- 
scojDes having internal illumination. 

Again in the case of externally illuminated instruments, such, for 
example, as Clar's photophore, much experience and considerable ef- 
fort are required to project the rays of light into the interior of the 
tube. Both the tube and the mirror being movable independently of 
one another, the operator is called upon to maintain a fixed and steady 
position, often tedious and difficult, in order to derive effective results, 

"S^Hien the light is attached to the proximal (outer) end of the tube, 
the lumen is obscured and a view is obtained only by the aid of a 
mirror perforated in its center. In some instances the apparatus is 
arranged with a system of reflection by a mirror and lenses which 
makes the handle of the instrument beavA^ and renders it uncomfortable 
for the patient and difficult for the surgeon to manipulate. Intra- 
urethral intervention is far more difficult and complicated, for it can be 
accomplished only with tlie aid of cumbersome and complex instru- 
ments with elbowed shafts. To conclude, it does not appear that 
urethroscopes with external illumination will ever be made that Avill 
be simple, practicable and easy to manipulate. 

EEFEEEXCE 
-LuTs: Bull, fie k Soe. de I'Inteniat., Feb. 22, 1905, p. 23. 

Urethroscopes With Internal Illumination 

In 1879 Xitze first conceived the idea of introducing the source of 
illumination down to the bottom of the tube, near the surface to be 
examined.' This is undoubtedly the ideal method of examination, for 
as he puts it, "in order to light up a room, one must carry a lamp into 
it.'" His instrument consisted of the ordinary urethroscopic tube 
(Fig. 16) in the wall of Avhich were three minute canals or channels. 
In one of these channels was an electric A\ire which led do^^m to the 
lamp placed at the extremity of the tube. The lamp consisted of an 
incandescent platinum ^viYe. The two other canals permitted the con- 
stant circulation of a stream of water, which prevented the over- 
heating of the instrument. This primitive instrument did not prove 
to be practical, however, for the lamp, being too large, diminished the 
visual field to a corresponding degree. 

Subsequently Leiter and particularly Oberlaender perfected this 
interesting method, and the latter deWsed a urethroscope which im- 
mediately showed marked superiority to all that had been employed 
previously. Oberlaender 's urethroscope (Fig. 17) affords a very dis- 



HISTORY OF URETHROSCOPY 



37 



liiicl \i('\v. 'riic plaliimiii wiic wliidi canics llic li.^lit projcK'ts l)ut 
slig'htlv' into Uh' Iuiiicii oi' ilic liilx- aii<l adniils ol' a very clear vieAV of 
a rather extensive portion of llic uiclliral mucosa. This instrument 
has two great disadvantages, liowevcr; iifst, it requii'cs the circuhitioii 
of water to cool the himj), thus necessitating an expensive and conipli- 
calcd outlii, and second, it compels the operator to withdraw the lamp 




Fig. 16. — Nitze's urethroscope. 

from the tube every time he desires to make a local application to tlie 
urethral mucosa. 

Valentine, of New York, fortunately corrected these faults by 
replacing the platinum incandescent wire with a very small electric 
bull) mounted on a thin metallic shaft which makes it possible to 1)ring 
the light doAra to the bottom of the tube. This lamp (Fig. 18) is sup- 
ported bv a handle which is provided with a current interrupter 
(Fig. 19)^. 

Apart from this modification, wliich, Ijy the way, was of great 




Fig. 17. — Obcrlaciiilcr's iircllnoscope. 

iin])oitance in its time, tlie other parts of Valentine's uretiiroscope 
do not vary materiallj^from that of Oberlaender. The tube and its 
obturator are identical with the Oberlaender-KoUmann (Fig. 20).' 
Kollmann, of Leipzig, has adapted tliis instrument, somewhat modilied, 
for taking photographs of the urethra.* His photographic urethro- 
scope is shown in Fig. 22. 

For the purpose of increasing tlie visual lield, Ivollmann with the 



38 CYSTOSCOPY AND URETHROSCOPY 

collaboration of Wiehe, devised a movable optical apparatus AvMch was 
introduced into the uretliroscopic tube and attached to the shank of 
the lamp (Fig. 23). 

Wasserthal, of Carlsbad, also modified the Valentine urethroscope 



Fig. 18. — Valentine's uretliroscopic lamp. 



by adopting Antal's old idea. He constructed an air urethroscope 
designed for examination of the urethral mucosa under distention mth 
compressed air, blown into the urethra (Fig. 24). Although this 
method affords an excellent profile examination of a large portion of 
the urethral mucosa, it has the disadvantage of not ]3ermitting a front 
view of the mucosa, an indispensable need in many instances. Gordon, 
of Vancouver,^ has constructed a urethroscope similar to the one just 
described (Fig. 25). 



<^^i 




Fig. 19. — Valentine's lamp carrier. 

Valentine's instrument has undergone still another modification 
on the part of R. Kaufmann (Fig. 26). This author attached a tele- 
scope in front of the urethroscope thus producing an enlargement of 
the urethral view. But this apparatus, rather heavy and cumbersome, 
presents certain difficulties in the performance of operative maneuvers 
within the tube. 

Demonchy's recent urethroscope has much in common with that 




Fig. 20. — Oberlaender-Kollmann uretliroscopic tube. 



of Kaufmann, differing from it, however, in the character of the 
handle. This handle, twelve centimeters in length, presents a plano- 
convex achromatic lens which gives a reversed picture. This is ex- 
amined and magnified through another lens, the eyepiece. This instru- 



iis'i'()i;>' oi' ri;i 



IIOSCOPY 



30 



iiH'iil lias doeidod (lisadxanla^cs, Ihc principal hcinu' its lack oi' siiii- 
])li('ity (tlio first essential of a good iiistriuneiit) ; in addition the handle 
is diflicnlt to control 1)ecause of its large size. A second disadvantage 




Fig. 21. — Valentine's urethroscopic outfit. 

is fonnd in the reversed pictnre, which does not give a view of the 
objects as they really are. All in all, this instrnment is too complicated 
and cumbersome to be practicable. 

From a practicable point of view, Valentine's instrnment actiiall\- 
had several distinct disadvantages. Whenever a lamp l)roke oi- Inii-iicd 
(Hit, it took great care and mnch time to replace it: the lam]i itself was 



^2^ 



mmitittudisiiim^^ mumtw tT ' ■•'■ 





Fig. 22. — Koliiiiann's photographic urethroscope. 



short-lived, for if a dro]i ol' linid got inside of its little metallic sheallu 
a short circuit was established, which burned it out ; though the ui-ethral 
lesions could be seen clearly, they might, nevertheless, occasionally 
remain undiscovered because the field was not magnified; lastly, the 



40 



CYSTOSCOPY AND URETHROSCOPY 



little lamp and its holder made an appreciable projection into tlie 
Imnen of the tube, thereby diminishing the visual field considerably. 
In the hope of remedying these disadvantages, I have devised a 
number of important modifications of this instrument, the first of 
which was presented before the Surgical Society on December 24,- 




Fig. 23. — Handle of Kolluiaiin-Wiehe's urethroscope, provided with an optic apparatus. 

1902, and later shoAoi to the Academy of Medicine by my teacher, Le 
Dentu.'' 

1. I added to the urethroscope an adjustable lens, the focus of 
which corresponded with the length of the urethroscopic tube. The 
urethral lesions are thus magnified and none of them can possibly be 




Fig. 2-1. — Wasserthal's aerourethroscope. 

overlooked. In order to observe the picture clearly, the presence of 
the magnifying glass is really very useful, and makes possible the 
study of interesting details Avhich can readily escape the unaided eye. 
The urethroscope being an instrument designed especially to afford 
an exact diagnosis, the great value of magnification in outlining th,e^ 



ji is'i'oi;^' oi' riii'rniijoscoi'v 



41 



details and cliaractcr oi' tiu! urethral mucosa can bo readily coniprc- 
iicndcd. It is therd'orc stra]i,ij,'e, to say the least, tliat certain iii,<;('nuous 
observers ai-e unwillin,"- to avail themselves of this important im- 
provement, on llie ,i;r()uii(l that tliey are obliged to i-ea<l,just the lens 
in makini;' local ai)plications. Moreover, a very recent inipi-o\-eiiient 




■^^""^■'^^^"'""""nn^^ 



afid- immnmrjrnmmnrmmrrmmn,nn,n„. 



zin.inuiiiumu.iiiimumrunimmTmr^^ 



"■"■'■"•■" ■■'■ I'l |'|( "iifi;"!"' 



vi'i/iiiii ii<rrii[ii"f""i"'ira(fL 




Fig. 25. — Gordon's endoscope. 



makes it possible for endourethral activities to ])e undertaken without 
adjusting the magnifying lens (see page 45). 

This lens is interchangeable easily, so that whether the operator 
is myopic, normal, or presbyopic, he can have a special lens made easily 



<Si 




rig. 26. — naudlc ami telcscupc of Kaufniann's iirctlircscope. 

which will give him a most perfect and distinct [)icture with the least 
effort. 

2. The shank of the lamp carrier has l)een [)erfected; the space 
l)etween the metallic shaft and the bulb has been filled in so that not a 
drop of fluid can enter and thus bring about a short circuit. 



42 CYSTOSCOPY AND URETHROSCOPY 

^ 3. Changing the lamp is a very simple procedure, and can be done 
in a few seconds. 

4. The lamps are mounted on slender rods of varying lengths, cor- 
responding to long or short nrethroscopic tubes, for examination of 
the anterior or posterior portions of the urethra respectively. 

5. Finally, at my suggestion, the nrethroscopic tubes have been 
hollowed out throughout their entire length with a little furrow, in 
Avhich the lamp and its carrier are retained ^^uthout interfering with 
the lumen of the tube. 

REFERENCES 

iNitzo : Eine neiie Beleuchtuiigs iind Uiitersucliungsmethode f iir Hariii'ohre, Harublase und 

Eectum, Wien. med. Wchnschr., 1879, N'o. 24. 
2Nitze: Lehrbuch der Kystokopie, ed. 2, Bergmann, 1907, p. 8. 
sOberlaender and KoUmann: Die chronisehe Gonorrhoe der mannlichen Harnrohre, Leipzig, 

1910, p. 64. 
^KoUmann: Die photographie des Harnrohre innern, Centralbl. f. d. Krankh. d. Harn-u. 

Sex.-Org., 1891, No. 391, p. 227. 
•''Gordon: Canadian Med. Assn. Jonr., December, 1911. 
6Le Dentu : Bull, de 1 'Acad, de med., Paris, Session of July 4, 1905, p. 4. 

In concluding this subject, it is fitting to mention the following, 
as the most interesting workers in the field of urethroscopy : 

iDe Keersmaecker and Verhoogen: Uretrites chroniques d'origiue gonoeoccique, Bruxelles, 

1898. 
sClado: Traite d'liysteroscopie, 1898. 

sFenwick: Obscure Disease of the Urethra, London, 1902. 
4Kollmann: Die Photographie des Harnrohre innern. Centralbl. f. d. Physiol, .u. Path. d. 

Harn-u. Sex.-Org., 1891. 
sValentine: The Irrigation Treatment of Gonorrhea, New York, Wm. Wood & Co., 1900, 

p. 188. 
eAlbuquerque, Azevedo: Endoscopia do appareilho urinario. These de Porto, 1903. 
7Stern, Charles: On the Use of the Urethroscope in Diagnosis, Tr. Connecticut State Med. 

Soc, 1906, pp. 137-145. 
sAsch, Paul: Urethroskopische Beitrage zur Diagnose Therapie und Prognose des Trippers 

und seiner Folgen: Ztschr. f. Urologie, 1907, i. No. 4. 
oLuys: Diagnostic et traitement uretroscopique des uretrites chroniques, Presse med., April 
22, 1903; Tr. Assn., fran§aise .d 'Urologie, 1903, p. 789; Endoscopic de I'uretre et de la 
vessie, Paris, Masson, 1905, Epuise; Exploration de I'appareil urinaire, ed. 1 and 2, 
1909, Paris, Masson. 
loWossidlo: Die Gonorrlroe des Mannes und ihre Komplicationen, Berlin, Otto Emslin, 1903, 

ed. 2, Georg Thieme, Leipzig, 1909. 
iiVon Frisch and Zuckerkandl: Handbiich der Urologie, Wicn. Holder, 1904, i, p. 550. 
i2Wormser: Journal des Praticiens, August 4, 1906. 
isSuarez de Mendoza: Diagnostico y Tratamiento de las enfermedades de las Vias urinarias, 

Madrid, Perlado Paez, 1908. 
iiOberlaender und Kollmaun : Die chronisehe Gonorrhoe der Mannlichen Harnrohre und irhre 

Komplicationen, ed. 2, Georg Thieme, Leipzig, 1910. 
isFraisse: Gonorrhea chronique de 1 'Homme, Paris, Maloine, 1910. 

isHenry, Eol)ert: Instrumentation et technique de I'uretroscopie posterieure. Jour, d 'Urol- 
ogie, iii, 1913, p. 767. 



HISTORY OF URETHROSCOPY 



43 



i"Wossidl(), pjvicJi: Die cliitniiHchcn ErkiMnkuii^on dcr liinlcrcn Hiiiiurilirr, Rorlin, Vorla^ 

Yon Werner Kliiikliardt, 191.",. 
isPiuil, Auguste: L'Uretr()seoj)ic, TliT'Sc, Paris, Oilier licniy, IHKl. 



Description of Luys' Urethroscope 

M)^ uretliroscopo consists of two distinct parts: 1. The iiretliro- 
scopic tuhes and their obturators; 2. The handle and the light cari-ici-. 

Urethroscopic Tubes. — The tubes present for examination a body 
or shaft and two extremities. The body is composed of a tube not 
perfectly cylindrical in shape; that is, on one of its walls throne-bout 




Fig. 27. — lyuys' long cystoscopic tube and its obturator. Inferiorly can be seen the longitudinal depres- 
sion for the lamp and its shaft. 

its entire length, a small groove or channel is found, which lodges the 
lamp and its carrier. In this way, instead of protruding into the lumen 
of the tube, the lamp and its carrier are hidden in the thickness of the 
wall and become a part of it ; this increases by a corresponding amount 
the inner diameter of the tube and accordingly enlarges the visual 
field. 

One of the extremities of the tube is designed to articulate Avith 




Fig. 28. — L,uys' short urethroscopic tube and its lamp. 



the handle; to it is attached a large circular flat collar which bears a 
small metallic projection upon which the handle is afhxed and tightened 
mth a screw, when in use. A slight notch in the margin of the collar 
makes the handle firm and immovable. The other extremity is blunt, 
in contrast with the German tubes, in order to protect the urethral 
mucosa from possible damage. 

Length of the Tubes. — The tubes I usually employ are of varied 
lengths, depending on the particular part of the urethra to lie examined. 
The long tubes are 14 cm. long (Fig. 27). They are designed espocially 
for examination of the posterior uretlira. The short tubes (Fig. 28) 



44 CYSTOSCOPY AND URETHKOSCOPY 

designed for the penile (anterior) urethra, are 7 cm. long. The me- 
dium-sized tubes are most frequently used; they measure 13 cm. in 
length. 

Caliber of the Tubes. — To determine the most desirable caliber 
for the urethroscopic tube, Oberlaender and Kollmann examined three 
hundred patients, and out of this number they found that only two or 
three per cent had a meatus too small to admit a No. 23 Charriere, 
while in the great majority of cases (69 to 70 per cent) No. 27 and even 
No. 29 was admitted easily. They concluded that No. 23 must be used 
in 10 per cent of patients, and No. 25 in 25 per cent of patients. These 
investigations show, therefore, that the greatest number of patients 
have a meatus sufficiently large to admit at least No. 25. My personal 
observations are in absolute accord ^yith. these figures, so that in most 
cases I use a No. 26 tube. 

In a general way, it may be said there is a decided advantage in 
using the largest possible tube, for the surface to be examined is 
thereby stretched and the folds of the mucosa disappear, so that 
minute lesions which would othermse be obscured, are brought to view. 

Material Used. — The tubes which I use are of metal, nickel-plated. 
Tubes of this kind are most easily cleaned, sterilized, and handled. 
Some operators iDref er glass tubes, because they are nonconductors. A 
short circuit may sometimes occur when the metallic lamp carrier is 
introduced into a metallic tube, and the current turned on, but this 
can easily be avoided if certain precautions are taken. On the other 
hand, however, the fragile nature of glass tubes gives ground for fear 
that they might break while in the canal and produce serious injury. 
Griinfeld, among others, has recommended hard rubber tubes; but 
these tubes do not seem to have au}^ advantage over the metal ones. 

The obturators, as opposed to those of German make, are full- 
plated metallic rods. Their manipulation and withdrawal from the 
tube offer no difficulties of any kind. In my first models a small groove 
ran along the entire length of the obturator, for the passage of a cur- 
rent of air on withdrawal of the obturator after the tube had been 
introduced. This prevented the urethral mucosa from being aspirated 
into the bottom of the tube. There was neither trauma nor j)ain. This 
plan did not prove practicable, however, and I have since had the 
wall of the tul^e grooved along its entire length, thus securing all the 
benefits, without the disadvantages, of the groove on the obturator. 

The Handle. — The handle consists of a metallic body long eiiough 
to offer a good purchase for the hand, and provided with an interrupter 
designed to make and l^reak the electric current. The electric wires 
which carrv the current are attached to its lowei' extremitv. At the 



HISTORY OF URETHROSCOPY 



45 



upper end is a inagiiifying lens, easily moval^le from side to side in a 
transverse direction. This lens, engaged in a small metallic circnlar 
liolder, is easily demountable, so that it can he changed readily to 
correspond with the size of tnhe emplo3^ed. Each size of tnhe has 
its corresponding lens, the focus of which is exactly suited to the 
length of the tube. 

Some observers have felt obliged to criticize my .employmeni of this 
lens, which they declare interferes with a clear urethral view. "The 
field is seen very well with the magnifying glass," they say, ''but if 
we wish to treat the mucosa and we move the lens, we can no longer 
see the details so well as before, and the local treatment becomes more 
difficult of application." To overcome this objection I have very small 





Fig. 29. — Handle of L,uys' urethroscope, show- 
ing the magnifying lens and the wires (front 
view). 



Fig. 30. — Improved model of the handle of 
Luys' urethroscope, in which the lens, much re- 
duced in size, need not be turned aside during 
endo urethral manipulations. 



lenses made which are maintained in place by a metallic frame attached 
to a slender holder (Figs. 29 and 30). Instruments can be introduced 
into the urethroscope alongside the margin of tliis lens. The latter, 
having the same diameter as that of the lumen of the tube, may re- 
main stationary, not only for observation of the uretliral nmcosa, but 
likewise in making local applications to the nmcosa. The lens, because 
of its small size, does not offer the slightest interference Avith intra- 
urethral manipulations and applications. 

With this simple optical system, it is no longer necessary to dis- 
])lace the magnifying lens in the case of eiidourethral interventiim, and 
it is at the same time possible to preserve the magnifuation j^crlVclly 
Ih rough out the examination. 



46 



CYSTOSCOPY AXD URETHEOSCOPY 



Finally, tlie small electric lamp is attaclied to the tuoe, mounted 
on a carrier of Yar^dng length, in accord /\^"itli the length of the tube. 
The light carriers are measured exactly so that the electric bulh approx- 
imates the lower extremity of the tube, T\'ithout, lioweYer, coming into 
contact with the mucosa. The ease and rapidity ^^^.th which a lamp can 
be changed or replaced are very strildng indeed, only a few moments 
being sufficient for the purpose. 

Urethroscopic tubes are sterilized by boiling : the lamps are steril- 
ized like the cystoscopic lamps; i. e., in formalin [or alcohol — Editor]. 

This is the instrument I have always operated with and with com- 
plete satisfaction. It answers any criticism that may be made regard- 
ing it. The danger of a burn is absolutely nil, for the cold lamps em- 




Eig« 31. — Profile view of Luys' urethroscope (complete^. 



ployed give forth no appreciable heat Avhile they are new. In all the 
examinations I have made, no patient has ever complained of any dis- 
agreeable sensation of heat. From this point of view it is well to change 
the lamp frequently and to have a stock always on hand, for they are 
quickly used up, and whereas AYhen new, they are absolutely cold, so 
that they may be held between the fingers, while lighted, YAithout any 
perception of heat, it is nevertheless true that after they have been used 
for some time they become hot and have to be replaced. In buying 
these lamps, only those having the smallest caliber and Avhicli are abso- 
lutely cold should be selected. On the other hand, enclourethral manip- 
ulations are cpiite possible with the lamp in situ. AU manipulations are 
done under the eye of the operator. Lastly, illunnnation of the urethral 
mucosa is perfect and far superior to that furnished by urethroscopes 
with external illumination. 



HISTORY or UrvETIlROSCOPY 



47 



Special Urethroscopes for the Posterior Urethra 

Because of the protrusion of the veruniontaiium into the urethra, 
the examination of the posterior portion of the canal presents special 
difficulties. The tip of a straight tube strikes against the anterior 
prominence of the verumontanum (Fig. 32), so that certain precau- 
tions are required to prevent its interference with the introduction of 
the instrument. This accounts for the many modifications adox)ted by 
various authors ; namely, elbowed instruments and distention of the 
posterior urethra. 

■ Goldschmidt conceived the idea of using water for the purpose of 




Fig. 32. — Illustrating 



V r^jtAfrj 



prominence of the verumontanum arrests and obstructs the extremity of 
the urethroscopic tube. 



dilatation; Wossidlo, following Antal, employed air. For my own 
part, after having tried endless improvements designed to secure 
a better knowledge of the posterior urethra, I have given up tliese 
complicated instruments entirely and have given preference to u\y 
simple tube. Handled cautiously, this tube has always in its favoi- its 
enviable simplicity and the extreme facility -\\'ith which it is managed. 
Goldschmidt's Irrigation Urethroscope for the Posterior Urethra. 
— This instrument (Fig. 35) is both interesting and useful in the ex- 
amination of the deep urethra. It resembles a model previously 
adopted by Le Fur (Figs. 33 and 34). In 1903 Le Fiir presented a 
urethroscope which was characterized by the fact that the lamp was 
attached to the end of the urethroscopic tube as in the cystoscope. 



48 



CYSTOSCOPY AND URETPIROSCOPY 



While tliis arrangement had the advantage of providing an nnob- 
strncted lumen in the tube, it had the drawback that the eye of the 
operator was dazzled by receiving the light rays directly against it, 
and as a result, the details of the mucosa could not be distinguished 
clearly/ 

This idea was taken up by Goldschmidt, of Berlin,- who, in 1906, 



Fig. 33. — L,e Fiir's urethroscopic lamp. 

devised an interesting urethroscope, with which excellent results can 
be obtained in special cases. He dilated the walls of the urethra with 
water under hj^drostatic pressure and thus examined the urethral mu- 
cosa. His instrument consists of two parts, one for the anterior ure- 
thra, the other for the posterior ; each of these contains an optical sys- 



7 



dC: 



^ 



M: 



Fig. 34. — L,e Fiir's urethroscope. 

tem which brings a rather large portion of the urethra under observa- 
tion, by enlarging the field of vision. 

Techjstic. — After emptying the bladder naturally, the patient is 
put in the position for cystoscopy; the head low, body horizontal, the 
buttocks at the edge of the table, the thighs flexed, and the heels sup- 




Fig. 35. — Goldschmidt's posterior urethroscope. 

ported by stirrups or footrests. The instrument and its obturator 
having been sterilized and lubricated with glycerin, it is introduced as 
far as the posterior urethra, which it enters readily because of its 
elbowed tip. The electric cable is connected with the rheostat, and 
the stopcock at the upper end of the tube is connected with an irri- 
gating jar containing warm water [preferably a mild antiseptic 



TTISTOKY or- rr.RTHROSCOPY 49 

solulioii — l^]i)i'i'()i; I ('lc\'nl('(l ahoiil Iwo iiiclci's ahoNc llic level of 
tJK' lahic. ''I'lie ohtiiralor is llieii w it lidiaw ii and the optical slieatli or 
t<'l('S('o])e is iiisei-1e(| and t iuhteiied in place. This hciiig donci, the 
stopcock is opened, tlie eh'ctric cnirent tui'iied on, and tlie posterior 
iirctlii'a is now examined l»y niovini; the instiaunent to and fro and 
rotatin.u' it, as iHupiired, The water runs naturally into the l)ladder; 
when the latter ])ecomes i'uU, the patient feels a desire to urinate. 
The current is tuiiied off, the stopcock closed, the telescope is with- 
drawn and tlie \\atei- in the bladder is permitted to escape into a 
di-ain attached to the tal)le. Goldschniidt has also devised an an- 
terior urethroscope based on the same princiiDle (Fig. 36). 

Advantages. — This instrument has notable advantages. A com- 
plete examination of the posterior urethra is made possible mthout 
interference by the presence of blood, the latter being constantly 
carried off by the stream of water into the bladder. Besides, the 
walls of the posterior urethra are well separated from one another, 
thus giving a clear view and distinct landmarks. Lastly the pic- 



<^^p< 




Fig. 36. — Goldschmidt's anterior urethroscope. 



tures are greatly magnified and the smallest details are discernibh^; 
even the smallest polj^pi float in the water and are easily recognized. 

Disadvantages. — Uyiifortunately the disadvantages of this instru- 
ment are more numerous than the advantages. To begin with, the 
apparatus is complicated necessarily. The management of the optical 
system and the essential presence of the current of water make this in- 
strument anything but a simple one. Again, the urethroscopic pictures 
are not seen as they really are; the mucosa is white, pale, and bloodless, 
for the water exerts pressure on it which i)roduces a localized anemia. 
Afoi'eover, it is impossible with this instrument to get a complete view of 
the entire posterior nrethra at one time. Only one wall of the urethra 
can be seen at once, for an entire half of tlie lumen of the instrument 
is taken up by the lamp. The supcM'ior wall, above the verumontanum, 
can not be examined at all, and this is a sei-ious defect. Finally, the 
endourethi'al intei-ventions, such as local a])i)lications and cauteriza- 
tion, are rather impractical and dithcult with this instrument. 

Summary. — Though this instrument is excellent for examination 



50 CYSTOSCOPY AND URETHROSCOPY 

purposes, its employment seems to be limited to those comparatively 
few cases in which it is desired to acqnire exact pathologic details of 
the posterior nrethra. Alfred Rothschild^ has devised some interesting 
modifications of Goldschmidt's instrument. 

Buerger's Cystourethroscope. — Buerger,'* of New York, has im- 
proved upon Goldschmidt's instrument by devising an apparatus which 
is based on the same principles as those of Nitze's first cystoscope (Fig. 
37). The defects which he finds in the Groldschniidt instrument are the 
limited field of vision, distortion of the pictures, and difficulty of manip- 
ulation because of the traumatism which it causes. 

Buerger's instrument does not possess these disadvantages; the 
pictures are magnified by virtue of a prism situated on the upper? wall 
of the instrument. 

Technic. — The tube armed with its obturator is inserted into the 
bladder; the latter is emx^tied through the tube, and the telescope is 
inserted on withdrawal of the obturator. The stream of water is intro- 



Fig. 37. — Buerger's cystourethroscope. 

duced by a lateral stopcock connected with an irrigator filled with warm 
antiseptic solution. The electric current is now turned on. The trigone 
is first examined, next the posterior urethra, the fluid being injected 
only from time to time. Not more than 50 to 150 c.c. of fluid may be 
necessar}^ The instrument can be turned in every direction because of 
the smallness of its mndow. 

This is essentially an examination instrument and is not practicable 
for endourethral work. This cardinal fault necessarily restricts its 
usefulness. 

Wossidlo's Posterior Urethroscope.— In 1908 Wossidlo' devised an 
instrument (Fig. 38) for x)osterior urethroscopy in which air Avas used 
for dilatation of the canal, but in a more recent model he also employs 
water for this purpose. This instrument undoubtedly presents a clear 
and distinct detailed view of the urethral mucosa, but it also has im- 
portant disadvantages. The principal one is that the instrument does 
not give a true picture. The object under examination is deformed by 
the optical system with its great magnification, to such an extent that 



HISTORY OF URETIIUOSCOPY 



51 



tlio i-oal condition of the mucosa can not he (Ictciiiiiiiod accurately. 
There is anotliei- great drawback, in tliat it is impossible; to operate on 
tlie lesions that tiie instrument reveals, because the optical apparatus 
interferes with the iiitiMxhidion and manijinlatioii oC instruments 
within the urethi'oscopic tube, so that when therapeutic intervention is 
attempted, the telescope must be removed; the mucosa previously mag- 
nified is now only dimly visible by the unaided eye. 

Donnnei', oi* Dresden, attempted to remedy these disad\ antages. 
He devised an optical apparatus whicli pei-niits tlie use ol' an elect rode. 
a curette, and a Instoury, while the apparatus is in position. The 
entire outfit is introduced in a Wossidlo urethroscopic tube; naturally 




Fig. 38. — Wossidlo's posterior urethroscope. 

the diameter of the tube is increased by several num1)ers, thus render- 
ing its ]-outine emplo^mient rather difficult. 

Summary.— Wossidlo's apparatus, like that of Goldschmidt and 
Demonchy, is complicated, the principal fault being that the optical 
apparatus is heavy and diflicult to manipulate. 



REFEEENCES 

iLe Fiir: Tr. Assn. fran^aise d 'Urologie, p. 784. 

-Goldschmidt: Die Endoscopic der Hainvcihre, Boil. klin. Wcluischr., Feb. 5, 190(>. No. fi ; 

Die Irrigations Urotroskopie, Folia Urologica, von .Tames Israel, 1907, i, Nos. 1 and 2. 
:iRnthscliild: Ztsehr. f. Urol., 190S, ii, ]^. TOOO; VitIuhkH. d. deuLscli. Gesellsch. f. Urologio. 

II Kongress in Berlin, April, 1909, p. 45S. 
^Buerger, Leo: On Methods of Posterior Urethroscopy, with a Description of a new Tysto- 

urethroscope, Am. Jour. Surg., May, 1910. 
■■Wossidlo: Ztsehr. f. Urol., 190S, p. 124:1; Deutsdi. iiic.l. W.4ni.schr.. 1910. No. 7. 



PLATE I 

Fig. 1. — Normal appearance of the prostatic fossette (postmoiitane space) 
situated between the bladder neck and the verumontanum. Below, the 
apex of the posterior wall of the verumontanum can be seen; above, 
can be seen the orifice of the bladder neck from which longitudinal 
folds descend in fan shape. 

Fig. 2. — Normal appearance, anterior vieiv of the verumontanum,, in which 
the prostatic utricle is distinctly seen. The upper part of the urethral 
mucosa is finely corrugated and constitutes a valuable landmark in 
determining the shape and size of the verumontanum. This is the 
most common view observed. 

Fig. 3. — Another normal aspect of the verumontanum, in which the pros- 
tatic utricle is not visible. Above are seen the corrugations of the 
urethral roof above the verumontanum; below, the anterior frenum of 
the verumontanum is recognized. 

Fig. 4. — Normal appearance, anterior aspect of the verumontanum, when 
the urethroscopic tube has been brought forward anterior to the pre- 
ceding figure. The protrusion of the verumontanum has diminished in 
height and width; in front of the verumontanum, its frenum is clearly 
seen; above, on the roof, the corrugations have increased the thick- 
ness of the mucosa appreciably. 

Fig. 5. — Appearance of a very considerably hypertrophied (juasturbator's) 
verumontanum. The organ here takes on the appearance of the uterine 
neck. 

Fig. 6. — Normal appearance, anterior surface of the verumontamm. The 
prostatic utricle is not visible, but on the lateral walls of the veru- 
montanum, two orifices are seen corresponding to the ejaculatory ducts 
(resembling a diver's helmet). 





ri«. 1. 



VvA. 2. 





Fig. 3. 



Fis. 4. 





PLATE I 



Fig. 6. 



HISTORY OF URETHROSCOPY 53 

Personal Experience with the Posterior Urethroscope. — The ex- 
cellent results obtained with my direct vision cystoscope and recto- 
scope induced me to adopt the same principles of examination for the 
posterior urethra. I, therefore, undertook a series of experiments and 
made attempts to improve upon the instruments devised for this pui-- 
pose. I constructed a tube similar to my direct vision cystoscope; 
that is, provided on its lower inner surface with a fine canal Avhich was 
open at the end of the tube and connected Avith tAvo stopcocks on the 
outside. Through this tiny canal it was possible to aspirate fluids or 
inject air by means of a rubber bulb. Illumination Avas proAdded by a 
small electric lamp mounted on a long stem or carrier. A small sheet 
of glass mounted on a metallic brace assured closure of the small orifice 
by adapting itself by pressure to the external orifice of the tube. This 
glass AvindoAv Avas to be used solely in connection Avith insufflation of 
the posterior urethra. 

Ada^antages. — ^AVhen air Avas forced into the deep urethra under 
pressure, perfect vision Avas obtained ; it was like a cloud being dissi- 
pated, a disappearing shadoAv, leaving- a perfect illuminated AdeAv of the 
A'erumontanum. Moreover, swabbing Avith cotton AA^as rarely needed, 
for the presence of the air Avas quite sufficient to dry up the slight 
oozing of blood and even the pathologic secretions. Inasmuch as the 
Avails of the urethra Avere Avidely separated from one another, a com- 
plete vieAV of the entire posterior urethra AA^as thus obtained. 

Another great advantage over the Avater-dilated instruments lay 
in the fact that the operator Avas not annoyed by the presence of air 
bubbles Avhich interfere Avith distinct vision b}^ filtering through the 
Avater. The color of the mucosa Avas hardly altered; it Avas not 
blanched as is the case Avith the Avater urethroscopes and its appear- 
ance Avas practically normal. 

Disadvantages. — The air Avhich served to dilate the posterior 
urethra, passing directly into the bladder, constituted the principal 
disadvantage. The bladder soon became full, resulting in a charac- 
teristic desire to void the urine. AVhen the prostate Avas small, noth- 
ing could be easier than to pass the tube gently into the bladder, open 
the tube, and evacuate the Adscus in this Avay. But Avhen the prostate 
Avas someAvhat enlarged, it became a difficult iiiatlci' to ('iii])ty tlic blad- 
der in this manner. This is certainly a disadvantage: the prostate 
formed a valve, so that the air entered readily but could not escape. 

To obviate this draAvback, I modified my first apparatus by curA'- 
ing its vesical extremity so as to permit its passing more easily into 
the bladder; I also placed a small opening at the end of the curA^e 
Avhich permitted the air, under pressure in the bladder, to be evacu- 



54 CYSTOSCOPY AND URETHROSCOPY 

ated easily through the stopcocks on the outside of the tube. The 
posterior urethra A¥as quite easily examined with this instrument. 
Frankly speaking, however, there are certain cases in which special 
methods of exploration are required, whichever instrument may be 
employed. 

In the vast majority of instances, my simple urethroscopic tube 
is quite sufficient to make a complete examination of the posterior 
urethra, pro^dded it is employed only after a thorough dilatation of 
the urethra with Benique sounds. The view thus obtained is perfect 
and we derive all the advantages of the special instruments Avithout 
enduring their disadvantages. Finally, when in certain very special 
cases it is necessary to examine the region of the bladder neck and 
especially its urethral sides, my direct vision cystoscope, male model, 
is preferable to any other instrument (see page 225). 

I venture to express the hope that the facility of management, 
precision of view and certainty of diagnosis which my urethroscope 
affords, will induce many physicians to return to urethroscopy, for 
many of the most zealous have had to abandon this valuable method 
of investigation after their first efforts, because of the difficulties in 
manipulating the instruments previously employed. If urethroscopy 
has been employed but little in France up to the present, the partic- 
ular reason must be found in this fact that the instruments put at the 
disposal of physicians have really been ver^^ clmnsy or else ver^^ com- 
plicated. I still think, after twelve years of experience, that my instru- 
ment deserves preference over other existing models, both for examina- 
tion and therapy, because it possesses the cardinal features which Ave 
have a rig:ht to demand of any instrument; namely, it is simple and 
practicable. 

HISTORY OF CYSTOSCOPY 

The first attempts to examine the vesical mucosa through the 
natural passages were made, as Ave haA^e seen, in the beginning of the 
nineteenth centurA^ At first all the investigators, following the lead 
of Desormeaux, sought to project light rays into the interior of a hol- 
loAV tube inserted into the bladder. But soon afterAA^ards, different 
and more complicated procedures made their appearance in rapid 
succession. 

Cruise, of Dublin,^ in 1865, substituted an elboAved tube for the 
straight one. This tube had an obtuse angle and was provided Avith a 
mirror at its angle. The instrument consisted of tAvo tubes, one of 
Avhich, a straight one, slid into the interior of the other. The inner 
straight tube had a little glass screen at its vesical end, Avhich pre- 



HISTORY OF CYSTOSCOPY 55 

vented the fliii<l in tlio bladder fi-oiii oljstructiiii;- tlio field of vision. 
The inner tube lioin^- movable, the l)ladder could be emptied readily 
when the fluid interfered with distinct vision. 

In an earlier model, Cruise had a glass Avindow at the vesical 
end of his tul)e; but wben the light was reflected strongly upon tlie 
mirror, it dazzled the operator and interfered with his viev,^ of the 
bladder. In a second model, he closed the terminal extremity of his 
tube completely and placed the glass window almost at right angles 
with the mirror. In this way the light and visual rays were both re- 
flected at 45 degrees and he thus obtained a reflected picture of the 
bladder, and even the bladder neck could be examined in this wa3^ 

The principle adopted by Bruck,- of Berlin, in 1867, was quite dif- 
ferent. Bruck's diaphanoscope aimed to illuminate the bladder indi- 
rectly. It was made of two distinct parts; the first consisted of a 
poAverful light emanating from an incandescent xolatinum mre, water- 
cooled. It had to be introduced into the rectum and was designed to 
illuminate the posterior wall of the bladder. The second part of the 
apparatus was a simple hollow metallic tube which was introduced into 
the urethra up to the bladder and permitted inspection of the vesical 
mucosa. Unfortunately this method did not furnish sufficient illumina- 
tion of the bladder wall, and a clear i^icture was therefore impossible. 
It was soon given up and discarded. 

Matters stood thus when the lamented Professor Xitze, in 187fi. 
began his study of the subject; and we must here acknowledge that 
this inventor rightfully deserves first place in the history of cystos- 
copy because of his epoch-making work on this subject. 

The new idea Avhich he contributed and which differed radically 
from those of his predecessors, was that instead of employing exter- 
nal illumination, as they had done, he brought the light into the blad- 
der itself; in his o^Am words,' ''in order to light up a room, it is neces- 
sary to bring the lamp along with you." 

However, in view of the narrow canal leading into the bladder, it 
became necessary to develop a method which would permit magnifi- 
cation of the visual field, before this idea could be made really prac- 
ticable. Nitze himself tells the circumstances in which this problem 
was solved. One day, in the hospital at Dresden, while examining 
the objective of a microscope to see whether it Avas cleai'. lie looked 
through the lens at a neighboring clmicli. Ife saw only a streak of 
liffht. Immediately the idea occurred to him that he could easily ob- 
tain an enlargement of the visual field willi a system of lenses. His 
i-esearches soon led to a system made up of lV)ur lenses combined with 
a prism. 



56 CTSTOSCOPY AXD UEETHEOSCOPT 

As a source of liglit. Xitze first made use of an incandescent 
platinnm film ^^itli Avliicli lie obtained a very good, clear light. Tliis 
had the disadvantage. hoAvever. of requiring circulation of Avater in 
order to aA'oid burning the mucosa.* This primitiA'e instrument AA^as 
im]DroA^ed and made more practicable through the aid Avhich Ijeiter, 
of Vienna, gave him in 1879: and the name Xitze-Leiter, has been 
given to this early model. This instrument Avas complicated. hoAv- 
ever, by the fact that the essential presence of Avater jDroA^ed imprac- 
ticable because of the difficulty of protecting the platinum AAure loop. 

Conditions remained thus until the discoA^ery of the Edison lamp. 
Applied inunediately to cystosco^Dy by Xitze. this modification brought 
a great imx^roA-ement to the original instrument, and in 18S7 Xitze 
constructed his final cystoscope Avhich is the underlying basis of all 
modern instruments. In this Avay, prismatic cystoscopy had its birth. 

EEFEEEXCES 

iCruise: Tlie Endoscope as an Aid iu the Diagnosis and Treatment of Disease: The Utility 

of the Endoscope, Dublin Quart. Jour. Med. Sc. May 1. 1865. 
2Bruck: Das L'retroscop und das Stomatoscop zur Durchleuchtung der Blase und der Zahue 

und ilirer Xachbartheile durch galvanisches Gliihlicht. Breslau, 1867. 
sXitze: Lehrbuch der Kystoskopie, Wiesbaden, Bergmann, 1907, ed. 2, p. 8. 
4]Sritze: Eine neue Beleuchtungs und Untersuchungsmethode fiir Harnrolire, Haiuljlase und 

Kectum. AVieu. med. AVchnsehr.. 1879. Xo. 24. 



History of Direct Vision Cystoscopy 

Coincident Avith the researches of Xitze and his folloAvers. other 
iiiA'estigations, of equal interest, Avere being conducted. At Vienna 
Griinfeld, in 1881, taking up the principle of Desormeaux's method, 
attempted to make a direct examination of the bladder in both sexes 
by means of a straight tube liaAung external frontal illumination. But 
the conditions under AA-hich he made his examinations of the A'esical 
caAdty Avere so imperfect that he deriA^ed but slight adA'antage from 
them. He actually looked at the A'esical mucosa through a stratum 
of urine Avliich he did not InioAv Iioav to eliminate. Xeither could he 
distinguish the ureteral orifices except in a A^ery imperfect manner, 
at least in the male subject. Later on. lu^ published reports of this 
method of cystosco^Dy in the treatment of l)ladd(^r tumors in the male 
and female.^ 

HoAvever, considerable progress folloAved Griinf eld's efforts, and 
he Avas soon aide to remoA'e bladder tumors by the natural routes and 
eA'en succeeded in catheteriziu"- the ureters in the female. All of these 



HISTORY OF CYSTOSCOPY 



57 



efforts, liowever, were merely stepping-stones in tlie direction of di- 
rect vision cystoscopy. 

To Kelly," of Baltimore, whose work goes Ijack to 1893, l)elongs 
the honor of having emphasized the importance of this method and 
of having indicated its great possibilities. Kelly made use of simple 




Fig. 39. — Kelly's endoscopic tube. 



tubes provided with minute canals in their Inmen, into which he sent 
Imninous rays by means of an external illumination attached to the 
forehead of the examiner. To dilate the bladder in the female, he 
had recourse to atmospheric air. He had previously observed that 




vim 



Fig. 40. — Method of holding Kclly"s endoscopic tube. 



the abdominal viscera are influenced by gravit>' in the genupectoral 
position, and are draA\'n doAmwards towards the diaphragm. This 
creates a tendency to a vacuum in the small pelvis which is made evi- 
dent by a sudden and complete dilatation of the bladder. When a 
hollow tube was introduced into the urethra penuitting the entrance 



58 



CYSTOSCOPY AND UEETHEOSCOPY 



.of air into tlie bladder, the latter became distended, to nse Ms OA^^l 
expression, "like a balloon tilled with air." Kelly employed this 
method in women with brilliant snccess. 

In 1898 he published a report on catheterization of the ureters in 
the male ^yith an open c3^sto scope.' 

Pawlick, of Prague,* constructed a direct \dsion cystoscope, in 
1898, which consisted of a speculum, provided Avitli a handle (Figs. 
41 and 42). He placed the patient in either the genupectoral or Tren- 
delenburg position, which brought about the distention of the bladder 
by the entrance of air. "With this instrument Pawlick examined the 
vesical ca^dty under the direct illumination of sunlight. AVhen the 





Fig. 



41 — Pawlick's endoscopic 
tube and obturator. 



Fig. 42. — Pawlick's endoscope with its lamp and irrigating 
apparatus. 



latter was not available, he employed electric illumination jDro^dded 
vdtlci an irrigation apparatus for cooling purposes. 

Kelly's work stimulated further improvements which were soon 
applied practicalh^ in his instruments. One of the most interesting 
was the improvement of Garceau, of Boston," who was the first to 
evacuate the bladder urine through an accessory canal included in 
the body of the urethroscopic tube adapted to the female. Pie con- 
structed an instrument of this kind (Fig. 43) in 1895. He soldered an 
accessory tube of tine caliber into a cystoscopic tube so that when the 
handle of the latter was turned toward the right side of the patient 
the accessory tube was rotated to the inferior Avail of the speculum. 
The urine was then aspirated by a Davidson syringe the bulb of 
which could be held by the hand which held the handle of the speculum 



HISTORY OF CYSTOSCOPY 



59 



SO that an assistant was not required. The simple idea of aspirating 
the urine as it was being secreted into the liladder, Avas sure to appeal 
to those Avho were using this instrument, and it soon had many imi- 
tators. In Europe it was our distinguished confrere, Hogge, of liege, 
who devised a similar instrument for use only in the female, in 1897.'' 
In this instrument, the aspirating canal, also soldered to the cysto- 
scopic tube, was joined on the outside to a rul)ber tube which termi- 
nated in a receptacle into wliicli the urine drained automatically. 
Through the courtesy of its inventor, I exhibited this instrument at 
the Urological Congress of 1905. 



@= 




Fig. 43.- — Garceau's endoscopic tube with its urine aspirator. 



Very curious and quite groundless is the claim of De Keers- 
maecker, of Antwerp,^ who claimed for himself priority of this im- 
provement. As a matter of fact, his first paper appeared two years 
after Garceau's first paper^ and more than six montlis later than 
Hogge 's first article, while De Keersmaecker passed over both eom- 
nmnications of his predecessor in silence. 

Other interesting changes were made by way of perfecting Kel- 
ly's combination of instruments. Among these, attention may now 
be called to the interesting cystoscope devised by Bransford Lewis, 
of St. Louis, who described his instrument and the technic of its use 
before the Association of Genitourinary Surgeons. The Lewis cysto- 



60 



CYSTOSCOPY AXD URETHROSCOPY 



scope consists of a tube to which are attached a handle and a beak, 
the latter enclosing a small cold electric lamp. The instrmiient is 
introduced into tlie bladder with the aid of an obturator, which is then 
mthdrawn. The jDroximal end of the tube is capj)ed A\T.th an eyepiece 
composed of a single lens which corrects the inversion of the picture. 

To dilate the bladder, Lewis^ introduces warm air which is re- 
tained under pressure by a stopcock. Special channels are attached 
for the passage of ureteral catheters. Finally, to insure magnifica- 
tion of the image as well as of the visual field, a telescope is intro- 
duced Avhich consists of a series of lenses and a prism. 

Technic. — The i)atient lies with the pelvis raised somewhat. The 
cystoscope is introduced, the obturator Adthdra^m, the bladder emp- 
tied of urine and the glass cap applied over the orifice of the tube. 
Warm air is now introduced into the bladder to distend it and the 




Fig. 44. — Cullen's cystoscope, without its optical part, the lamp reversed, emitting vertical rays downward. 

electric current turned on. In this way the bladder may be examined, 
taking the precaution to aspirate the urine from the bladder from 
time to time ^Adth a syringe. Single or double catheterization of the 
ureters ma^^ thus be easily accomplished. 

In 1903 Thomas CuUen" devised a bent cystoscopic tube con- 
taining no optical apparatus in its interior, but provided with an 
inverted lamp at its elbow which emitted vertical luminous rays from 
above do^mward (Fig. 44). This instrument was the basis of a more 
complicated and impracticable instrument presented nevertheless as 
original to the Surgical Society of Paris in May, 1905. It does not 
appear, however, that this apparatus can give satisfactory results. 
Indeed, every cystoscopic tube with an immovable elbow has a two- 
fold defect. On the one hand, intravesical mp.nipulation is difficult 
for the surgeon and painful to the patient, the elbow preventing easy 



HISTORY OF CYSTOSCOPY 61 

movement of the instrument within the bladder; on the other Inmd, 
with such an instrument, only the base of the bladder is visible, and 
the remainder of the viscus remains unexplored. 

These two principal faults, which are of serious character, ren- 
dered an}" possible additional effort in this direction practically use- 
less. In point of fact there is undoubtedly a great advantag-e in 
maintaining the straight form for the endoscopic tube. Its clean-cut 
edges permit the localization of a point such as the ureteral orifice 
and bringing it into the interior of the tube, just as the uterine cervix 
is brought within the lips of the vaginal speculum. 

In France direct vision cystoscopy has been practiced but little, 
and up to the present but few authors have adopted it. One of the 
first works on the subject, is that of Janet" who, in 1891, devised a 
double endoscope, consisting of an internal tube provided AAith a win- 
dow which fitted into the interior of an outer tube. AVith this appa- 
ratus Janet succeeded in examining the vesical mucosa. He inserted 
the instrument directly up to that portion of the bladder which was 
to be examined or treated, and on withdrawing the inner fenestrated 
tube, he thus obtained the bladder area upon which he could operate 
through the remaining external tube mthout the escaiDe of the dis- 
tending fluid. 

In 1898 Clado'' recommended the Trendelenburg position for dis- 
tending the female bladder. Paul Delbet,'" in 1902, devised an endo- 
scope with blades that spread out like a fan within the bladder owing 
to a mechanism constructed on the principle of the iris diaphragm. 
This instrument could be used only in the female. Moreover the steel 
blades did not always approximate exactly at the end of the examina- 
tion, and sometimes nipped the mucosa, doing more or less damage. 
In brief, this instrument, though ingenious, was a delicate affair, and 
thus failed to attain general popularity. In 1902 Clarence Webster/^ 
of Chicago, and in 1903, Hartmann'' also reconmiended the Trendelen- 
l)urg iDosition for the examination of the female bladder. 

I began to study this question in 1902, after liaving completed my 
urethroscope," when I immediately attempted to extend its field of 
usefulness from the urethra to the bladder. But it was not until Octo- 
ber, 1904, that I presented before the Congress of Urology a direct 
vision cystoscope which gave me excellent results in the examination 
of the female bladder." Applying later to tlie male what I first ac- 
complished for the female, I constructed a direct vision cystoscope 
for the male Avhich was presented to the Surgical Society on March 1, 
1905.'' My results and observations Avere announced in my Avork on 
"The Endoscopy of the Urethra and Bladder" which appeared in 



bZ CYSTOSCOPY AXD URETHROSCOPY 

April, 1905." This work was presented before the Academy of Med- 
icine by my former teacher, Le Dentu.-° In June, 1905, I described 
my instrument and its technic in the Presse medicale-^ and in the An- 
nates de gynecologie et d'obstetriquer^ 

The splendid results obtained through direct vision cystoscop^^ 
with my instrument were described in the Annates cjenito-urinaires.^^ 
In October, 1905, I reported in detail to the Congress of Urology the 
recent improvements in my instrument which produced an image and 
illumination far superior to those previously attained.-* In Novem- 
ber, 1905, I demonstrated'-' the valuable aid which nw direct vision 
cystoscope gave in seeking foreign bodies in the bladder and I showed 
the ease with which such bodies even of large size could be removed 
from that organ.^*^ As a cro^^ming of my efforts in this direction, the 
Faculty of Medicine late in 1905 did me the honor to award the Bar- 
bier prize for my direct vision cystoscope. Since then I have con- 
tinued to study the question and have profited by the lessons of 
experience to learn the great advantages which can be derived from 
this interesting method. 

In 1906^^ the results attained with the direct ^T^sion cystoscope 
were pointed out and further elaborated.^^ In 1907 the simple treat- 
ment of bladder tumors was described.^^ In 1909 the great advan- 
tage of direct vision cystoscopy in searching for ureteral calculi was 
demonstrated,'" and three years later the treatment of phosphatic 
bladder stones was described.^^ A resume of the advances in direct 
vision cystoscopy has been published recently.'^ 

Since my first publications, many papers have been written and 
numerous modifications have been suggested for my instrument. Jean 
Ferron, of Bordeaux, thought that in certain circumstances it would 
be advisable to shorten the male cystoscopic tubes. Instead of 18 cm. 
which my cystoscope measures, Ferron employed tubes 15 cm. in 
length and at times he even employed tubes measuring only l.S cm. 
The change in length has the advantage of improving the view, for 
the nearer we approach the object to be observed, the more clearly 
the details appear. In the same way, Ferron made tubes of varying 
calibers, even up to No. 48 Benique. These modifications are of in- 
terest, and must be used only in certain cases. 

Among the other articles which have given most attention to this 
subject, the following may be read with profit' Those of Boari'" of 
Ancona ; Bickersteth f^ Gauthier,'^ of Lyons ; and finally the very in- 
teresting thesis of P. Jardon,'*^ which appeared at Bordeaux in 1912, 
in which the author shows that ''in many cases direct vision can be 
employed in the same way and with the same advantages as the 



TTTSTOTIY OK CYSTOSCOPY bo 

prism." As lie rurllici- rciiini-ks, llic use of dii-cci x'isioii cystoscopy 
"should Ix' iiioic widespread tliau it is at present." 

REFERENCES 

iGriinfekl: Ueber Cystoskoiiic ini All-cim iiicn und iilicr I'.liisciit iiiiior(Mi irii Besomlcrji, 

Wieii. klin. Wclmschr., 1889, No. 21, p. 42;!. 
^Kelly: Bull. Johns Hoi^kiiis Hosp., December, 189:5; Am. .loiir. Obst., Jaimaiy, 1894; ibid., 

July, 1894, No. 85. 
:iKelly: Cystoscopy and Catheterization of the Uietcrs in the Male, Ann. Surg., April, 1898. 
4Pa\vlick: Zentralbl. f. Gyuac, 1896 j Revue gynecol. d diii'. abdoni., October, 1897, pp. 

786-822. 
nGarceau: B^oston Med. and Surg. Jour., Oct. 1?,, 1895, p. 444. 
eHogge: Cystoscope a lumiere externe pour le catheterisme permanent des ureteres chez 

la femme, Soc. med.-chir. de Liege, April 1, 1897; Ann. Soc. med.-chir. de Liege, June, 

1897. 
7De Keersmaecker : Societe beige d'Urologie, June 6, 1905. 

8De Keersmaecker: Ann. Soc. beige de Chir., Dec. 18, 1897, v, Nos. 5 and 6, pp. 165, 166, 167. 
oLewis: Jour, of Cutan. and Genito-Urin. Dis., 1900, p. 420. 
if'Cullen: A Simple Electric Female Cystoscope, Bull. Johns Hopkins Hosp., June, 1903. 
n Janet-: Un nouvel endoscope uretro-cystique, Ann. d. mal. d. org. genito-urin., 1891, p. 627; 

Revue generale d. Sciences, March 15, 1892. 
isClado: La cystoscopie dans le diagnostic des affections de la vessie chez la femme, Tr. 

Assn. frang. d'Urologie, 1893, p. 333. 
]3Delbet: Speculum endo-vesical pour I'examen du trigone et du bas-fond chez la femme, 

Tr. Assn. fran§. d'Urologie, 1902, p. 679. 
i4Webster: J'our. Am. Med. Assn., May, 1902. 
isHartmann: La cystoscopie directe chez la femme, in Travaux de ehirurgie anatomo-cli- 

niques, Paris, Steinheil, 1902, p. 43. 
leLuys: Bull, et mem. Soc. de chir. de Paris, Dec. 24, 1902; Presse med., April 22, 1903. 
i-Luys: Tr. Assn. franQ. d'Urologie, 1904, p. 522; De I'application de 1 'uretroscopie a 

I'examen de la vessie et au traitement des cystites de la femme. 
i.sLuys: Bull, et mem. Soc. de chir. de Paris, March 7, 1905, pp. 224 and 244. 
i9Luys: Endoscopic de I'uretre et de la vessie, Paris, Masson, 1905. (Out of print.) 
2oLe Dentu: Bull, de I'Acad. de med., Paris, July 4, 1905, p. 4. 
2iLuys: La cystoscopie a vision directe, Presse med., June 24, 1905, p. 39. 
22Luysi La cystoscopie directe chez la femme, Ann. d. gynee. et d 'obst.. May, 1905, p. 292. 
23Luys: Ann. genito-urin., July 15, 1905. 
24Luys: Tr. Assn. fran^,. d'Urologie, 1905, pp. 467-482. 
25Luys: Presse med., Nov. 29, 1905; Rev. prat. d. mal. d. org. genito-urin. du Dr. Gallois, 

January 1, 1906. 
26Luys: La Clinique, Octav Doin, editor, April 13, 1906, p. 230. 

27Luys: Nev^^ Direct Vision Cystoscope, Paris Med. Jour., April, 1006. i. No. 1, April, 190(). 
28Luys: Des indications de la Cystoscopie a vision directe, Tr. 10th session Assn. fran^. 

d'Urologie, October, 1906, p. 382. 
-•iiLuys: La Cystoscopie a vision directe dans lo traitonient des tunu'urs de la vessie, Tr. 

11th session, Assn. fran?. d'Urologie, October, 1907, p. 407. 
:i"Luys: La cystoscopie a vision directe dans la recherche des calculs tie Turetere, Tr. l.'Uli 

session, Assn. fran^. d'Urol'Ogie, OetoluM-, 11MI9, ]\ 2iti>. 
3iLuys: La Cystoscopie a vision directe dans h' Iraitcnicnl des caknils phosphatiques, Tr. 

16th session Assn. franc. d'Urologie, Octolicr. 1912, p. 694. 
•■•2Luys: Ueber die direkte Cystoskopio, Ztschr. f. Uroiogische Chir., March 7, 191.3, i. Parts 
1 and 2, p. 103. 



64 CYSTOSCOPY Aj^D URETHROSCOPY 

ssBoari, (d'Ancone) : Estratto degli Atti della Societa italiana di Urologio, Congresso di 
Eoma, April, 15, 16, 1908 ; Ann. d. mal. d. org. genito-urin., 1908, ii. 

34Bickersteth : Catheterization of the Ureters and Its Uses, Lancet, London, May 18, 1912. 

35Gauthier : Indications de la Cystoseopie a vision directe, Ann. d. mal. d. org. genito-urin., 
1910 ; Lyon nied., April 11, 1909. 

36Jardon: De la Cystoseopie a vision directe sel-on les procedes modernes. These Imprimeria 
Moderne, A. Destout, Senior & Co., Bordeaux, 1912. 



CHAPTER II 
URETHEOSCOPY 

Importance of Urethroscopy. — Urethroscopy may he defined as 
the study of the urethral mucosa under the direct control of the eye 
by the aid of the urethroscope. In order to attain an exact idea of 
the utility of urethroscopy, and of the su]oreme importance of the di- 
rect examination of the urethral canal, it is necessary to understand 
fully the great service which this method of examination can render 
in the diseases of the urethra, and especially in that disease which 
is most frequent; namel}^, chronic urethritis. 

Urethroscopy in Chronic Urethritis. — We know now that chronic 
urethritis is a purely local disease and that the foci of infection 
which perpetuate and prolong it are, in the vast majority of cases, 
thoroughly localized and circumscribed. A thorough knowledge and 
understanding of these foci, so that they may be treated according 
to their respective varieties, constitute the secret of the cure of 
chronic urethritis. The instruments and the methods designed to ex- 
plore the urethra and its adnexa have been numerous, and have been 
employed over a long x>eriod of time; and among the methods of ex- 
X)loration, urethral endoscopy possesses a value of the highest order 
both in the diagnosis and the treatment of urethral disease. 

The urethroscope is for the urethra what the stethoscope is for 
the heart, Avhat the roentgen rays are for fractures, what the lar- 
yngoscope is for the larynx, what the ophthalmoscope is for tlie eye. 
While the stethoscope may not be needed in the diagnosis of a gross 
lesion of the heart, it is nevertheless true that this valuable instru- 
ment will enable us to determine and localize a faint cardiac mur- 
mur quite distinctly. Likewise though the diagnosis of a fracture 
can readily be made by a number of clinical and pathognomonic symp- 
toms, it is equally true tliat the roentgen rays and the fhioroscope en- 
able us in many cases to locate exactly tlie direction of the line of 
fracture and to determine the method of treatment, appropriate and 
beneficial to the patient. It is precisely in tlie same circumstances, 
but with a still greater need, that the urethroscope enables us to 
localize the lesion quite exactly at a particular portion of the urethra. 

The scientific mind must be averse to instituting a method of 

65 



PLATE II 

Fig. 1. — Long cel-slwpecl polypus on the anterior aspect of the verunK^n- 
tanum. 

Fig. 2. — Long pliallus-shaped polypus on the apex or crest of the veni- 
montanum. 




Fig. 1. 




Fig. 2. 

PLATE II 



URETHROSCOPY 67 

therapy ai;'ainst a j)a11i()l(),i;i(' ciilily \\!ii('li is iiol known in all its do- 
tails. SiU'li a procedure would he a step in Ili«' dark and Avouid ])rac- 
lieally rediiee llie treatment oL' uretliritis to an empii'ieisni wlncli is 
no longer in liarniony with the present time. 

The nrctlii-al walls ai-c not visil)k; naturally and only the gi'oss 
urethral lesions are recognized through the means ordinarily em- 
ployed. The aim of urethroscopy, however, is to see the localized 
urethral lesion,— to know its exact situation, as well as its size and 
shape. By this method of investigation we are enabled to ap])ly to 
the urethral nmcosa the principle of all rational surgery; namely, to 
make an exact diagnosis of the urethral lesions by looking directly 
at them and treating them subsequently according to the diagnosis 
thus determined. There is but one method by which the folds and re- 
cesses of the urethra can be studied and that is by looking at them 
directly through the urethroscope. This instrument better than any 
other brings to view the chronic foci by localizing the lesions in the 
urethra. It is true, of course, that the seat of the lesions in the ure- 
thra ma)^ be determined in a general way by examination of the urine 
and its shreds passed into several glasses, but this method does not 
tell us in which i^articular portion of the urethra the foci are situattMl, 
nor does it tell us anything of their character. 

The anterior urethra is comparatively long and the methods of 
treatment applicable to its lesions vary considerably, and the instru- 
ments employed also differ considerably according to the location of 
the infection. Lesions of Littre's glands of the penile urethra, for 
example, are not treated in the same manner as inflammations situ- 
ated at the bulb. And how can one be sure of the exact location if the 
lesion has not actually been seen with the eye? The urethroscope alone 
meets this demand. And we may add that besides the precision in 
the means of localization which urethroscopy offers, this metliod also 
affords the possibility of energetic local treatment applied directly to 
the lesions. The great value and importance of this method of ther- 
apy nuist be emphasized; and it is also proper to indicate how il- 
logical it would be to attempt the treatment of a surgical lesion with- 
out seeing it. 

Lastly, urethroscopy enables ns to note clearly and precisely tlu^ 
results ol)tained dui-ing a methodical course of treatment. In ure- 
thral dilatation for sti-icture, the progrc^ss of th.e case can hv I'oHowimI 
step by step; and when bleeding takes jilace, we can not only locate 
the tear, but also determine the appropriate intervals for dilatatu)n. 
As a matter of fact, so long as the tear caused by the dilatation is 
not entirely cicatrized, repeated dilatation meiely separates the ends 



68 CYSTOSCOPY AND URETHROSCOPY 

of the tear without serving any benefit to the remainder of the ure- 
thral circumference. Beneficial when carried on prudently under the 
control of the urethroscope, dilatation ma}^ be of no actual value and 
even disastrous when it is done blindly. 

It must appear after all that has just been said, that the criti- 
cisms generally aimed at urethroscopy must fall of their OA\ai weight. 
The argument so often made that urethroscopy does not teach us 
anything that we can not learn clinically, does not seem to us worthy 
of consideration. Just one glance at the draAvings which we publish 
will suffice to indicate how the mysterious veil thrown over the eti- 
ology of certain refractory urethritides has been set aside by the use 
of the urethroscope, and it also explains the real reason for the check 
which older methods of treatment have received since its use has be- 
come widespread. 

In the matter of accidents which may result from urethroscopy^, 
such as eiDididymitis, cystitis, etc., they mil be positivel}' avoided if 
the proper technic is employed (see page 74). ITrethroscop}^ should, 
of course, never be emplo^^ed in the diagnosis of lesions which are 
acute, extensive, or recent; it should be utilized onl}^ under certain 
Avell-defined conditions which are specified later on; and, it may be 
added, if carried out with pro^Der precautions, this method will never 
give rise to the least untoward complication. 

Conclusion. — UretJiroscopy must he accepted as a routine m-ethod 
of urethral exploration. From the standpoint of diagnosis it furnishes 
informcition infinitely more usefid than any other method of investiga- 
tion; and from the therapeutic point of vieiv it enables the practitioner 
to act precisely as ivell as effectively. And finally, in the treatment of 
chronic urethritis it is absolutely indispenscible. 

Moreover, when endoscop^^ has been employed for some time in 
the urethra or the bladder, and when the operating and instrumental 
technic have been fully mastered, it is difficult to conceive why this val- 
uable aid in diagnosis and treatment is not always utilized. Congested 
areas, ecch^auoses, soft infiltrations of the mucosa, — all of these are 
beautifully seen; \n.i\\ patience and proper equipment one can enjoy 
the sensation of actuall}^ doing real scientific work, both surgical as 
well as useful. 

The Importance of Urethroscopy in Determining the Absolute Cure 
of Urethritis. — It is needless to insist on the great importance of de- 
termining whether a patient is or is not completely cured of his ure- 
thritis. As we all know, this is a matter of vital interest, for it may 
be the means of avoiding terrible and even fatal consequences in the 
future. Undoubtedly, valuable information as to a cure can be de- 



URETHROSCOPY . 69 

rived from a cai-crul cxainiiiatioii ol' the iii-iiK; wliicli has been retained 
several liours and a study of tlic rilainciits A\liicli it contains. Likc- 
mse, massage of tlie urethral glands and the exploration of the ure- 
thral mucosa stretched upon a curved Beniquc sound will also fur- 
nish most valuahle information. Ijut it is equally true that surpris- 
ing relapses often occur, notwithstanding these tests. These relapses 
often can not be explained. 

In cases Avhere marriage has been permitted prematurely, fatal 
consequences may ensue. It is our duty, in every case of approach- 
ing marriage, to take every loossible precaution to avoid future dis- 
aster. Among these precautions the most important is the minute 
examination of the entire urethral mucosa by means of the urethro- 
scope. For it is only through this medium that we can obtain the 
most detailed and exact data, in order to determine a complete cure 
and thus deliver to the patient his "certificate of health" wliicli will 
enable him to enter the marriage state in complete moral and physical 
security. 

it may he safely stated that the perfect and sure cure of a ure- 
thritis shoidd not he affirmed ivithout a complete and minute %ire- 
throscopic examination of the urethrcd mucosa' having heen made. 

Several instances mentioned further on, in Avhich the gonococcus 
has persisted in the urethra over a period of many years Avithout 
arousing suspicion, Avill demonstrate the absolute necessity of ure- 
throscopic control before marriage is permitted. We can not do bet- 
ter than to recall the opinion of Oberlaender and Kollmann,^ on this 
subject : 

"However mild the case under observation may have been, one 
should not be content with a single examination in forming an opinion 
as to a cure; to the contrary, many examinations should be made, not 
only at an interval of several days, but for several weeks in succes- 
sion, and on each occasion, the urethroscope must be employed, the 
patient not having urinated for five or six hours. Cocaine must not 
be employed. The entire canal shoidd be examined from end to end. 
To be sure that tlie cure is complete, the canal, which has been ex- 
amined, must fulfill these conditions: 

"The mucosa nmst present noi'iiial I'olds, with iicrfcct longitu- 
<linal ridges or furrows. There must be no di1'f(U'euce in color l)etween 
the parts originally affected and those which remained healthy. Tlie 
epithelium should be bright throughout. The orifices of the lacuna^ 
and of Littre's glands nuist show no evidence of irritation, and tlie 
periglandular infiltrations and the cicatrices of the deep-seated glands 



70 CYSTOSCOPY AND UEETHEOSCOPY ^ 

should not appear at the mucous surface, but should present a healthy 
epithelial surface like the rest of the canal. 

"Cicatrices which may have formed beneath the epithelium should 
be no longer distinguishable, but should be covered over with a nor- 
mal epithelial surface." 

Indeed Avhen it is a matter involving so grave a responsibility 
as that of granting permission to marry, it is essential that every 
possible precaution should be taken, and Ave can not fail to subscribe 
most heartily to the indications laid down by Ol^erlaender and Koll- 
mann. But it is true, nevertheless, that in many instances Ave can 
not possibl}^ hope for a complete restitutio ad integrum. This is nota- 
bly true, for example, in the case of strictures. 

As soon as ^ve are assured that there is no further possible con- 
tamination from the gonococcus or other organisms, and Avlien this 
decision has been arriA^ed at by the faithful use of the urethroscope, 
Ave may AAdth reasonable assurance declare that there no longer ex- 
ists any germ focus and that the proposed marriage may then be 
sanctioned. 

EEFEPvEE-CE 
iQlaerlaender uud Kollmann : Die clironisclio Goiionhoe, Leipzig, 1901, p. 168. 

TECHNIC OF URETHROSCOPY 

Preparation of the Instruments. — The examining table should be 
eleA^ated, and AvheneA^er possible, proAdded Avith an adjustable back. 
Footrests or stirrups are attached to the front legs (Fig. 45). The 
instrument is made ready and tested, after having taken pro|)er care 
to insure perfect Avorking of the instrument, connecting Avires, etc. 
The source of light for the small electric lamp A^aries. The light is 
usually derived from the city electric current by means of a rheostat, 
Avhich regulates at AAill the amount of current in the lamp. The models 
of Heller (Fig. 46), Gaiffe (Fig. 47), T.oeAvenstein (Fig. 48) and of 
Leiter are most frequently emiDloyed, In America, a "transformer" 
knoAvn as a "controller" or rheostat is generall}^ used (Fig. 49). This 
regulates the tension of the current from zero up to 25 A^olts; it is 
X)ractical and inexpensive. 

When the city current is not available, a dry battery may be used. 
True, it is short-liA^ed, but it is easil}^ reneAved (Fig. 50). Because of 
their small size the}^ are easily carried about in the pocket; but their 
short life is a decided disadvantage. An electric turbine maA^ also 
be employed, proAdded Avater under pressure is aA^ailable, to make 



TECIINIC OF URETiniOSCOPY 



71 



tlic turbino rotate. The electric turbine consists of a dynamo with a 
magnet, upon the axis of which is provided a large aluminmn ring. 
The inner surface of this ring is corrugated; two powerful jets of 
water falling oliliquely and proceeding from two pipes placed one 
opposite the other, cause the rotation of the magnets and thereby 
produce the current. 

Sigurta, of Milan,^ has devised a very interesting method which 
can render great service w^hen electricity can not be had. This appa- 
ratus (Fig. 51) is made up of a small dynamo, the action of which 




Fig. 45. — Urethroscopic examining table (author's model). 

is produced by a flying gear, which is set in motion by the hand of an 
assistant. The rapidity of the movements transmitted to the dynamo 
determines the intensity of the current and the voltage of the lamp. 
A very sensitive indicator regulates the current employed. 

The source of light having been provided, the handle of the ure- 
throscope with its lamp, is connected with a cal)le to the rheostat and 
the current is turned on gradually until a white light is obtained in 
the lamp. The urethroscopic tubes are selected according to the in- 
dividual case. If the anterior urethra is to be examined, a short 7 cm. 



72 



CYSTOSCOPY AXD USETHEOSCOPY 




Fig. 46. — Rheostat for light and cautery adapted for city current (Heller). 

tube is to be jDref erred, for a clearer view is tliiis produced. If, on 
the contrary, tlie entire nretlira is to be studied, the long 13 cm. tube 
should be selected. For the posterior urethra and prostatic lesions 




Fig. 47. — Rheostat for light and cautery, using city current (Gaifie). 



TECHNIC OF URETHROSCOPY 



73 



(veru) particularly, tlic longer 14 cm, tiihc Avill give the best results. 
It goes without saying that each of these various sized tubes is pro- 




Fig. 48. — RTieostat for light, using city current (Loewenstein). 

vided Avith a lamp carrier of corresponding length. The caliber of 
the tube most connnonly used is 24 or 26, and even 28 French, if it 



l^^\ \ 




Fig. 49. — Light controller. 




Fig. 50. — Pocket battery. 



Avill pass the meatus. The magnifying lens corresponding to the focal 
length of the tube is now adjusted to the handle. 



74 



CYSTOSCOPY AND UEETHEOSCOPY 



The special instruments required for the local treatment of the 
urethral lesions are placed on a table to the right of the operator, so 
that the diagnosis may be made and the treatment applied at the same 




Fig. 51. — Sigurta's portable batter}^ for electric illumination. 

sitting. These instruments are the following: AVooden cotton car- 
riers or applicators, both ends capped Avith cotton (Fig. 52) ; a pair 
of long forceps, designed for the recovery of cotton which may drop 



Fig. 52. — Wooden cotton carrier. 



from the applicator; a tine wire cautery and a Kollmann electrolytic 
needle. The tubes and their obturators are sterilized by boiling. 

Preparation of the Patient. — The lower garments are removed 




Fig. 53. — Special forceps for intraurethral work. 



and the feet and legs encased in operating stockings. The bladder 
should be full preferably. The patient lies on his back, the feet rest- 



TECHNIC OF URETHROSCOPY 



ro 



ing in the stirrups, the buttocks drawm Avell forward to the edge of 
the table (Figs. 54 and 55). For the posterior urethra alone, the 
lithotomy position is to be preferred. The patient and instruments 




Fig. 54.— Examination of the anterior urethra; showing position of operator and patient. 




Fig. SS.-Examination of the posterior urethra; showing position of operator and patient. 

thus prepared, the glans and the meatus are cleansed with a mild 
antiseptic solution. 



76 



CYSTOSCOPY AXD UEETHEOSCOPY 



Examination of the Posterior Urethra. — Previous to the urethro- 
scopic examination, it mnst be deteniiined that tlie meatus is large 
enough to admit the passage of the uretliroscopic tube, and that there 
is no stricture in the urethra of a caliber sufficiently small to obstruct 
the tube. In the normal urethra, the meatus constitutes the narrow- 
est portion of the canal; it may, therefore, be necessary to perform 




Fig. 56. — Ten c.c. syringe, for intraurethral injection of cocaine or stovaine; can be boiled. 



meatotomy if the meatus is too small to permit the passage of a 
uretliroscopic tube Avithout x)ain. 

Unless there are special indications, it is advisable that nothing 
be injected into the urethra before the examination, in order that any 
retained glandular or other secretions shall remain for observation 
and study. ^Mien the examhiation is comiDlete, the urethra is washed 




Introduction of the iiretbroscopic tube into the posterior urethra. 



out thoroughly by the x)atient voiding the urine in the natural manner. 
Occasionally, in sensitive or nervous patients, it Avill be necessary 
to anesthetize the urethral mucosa. This is best done by injecting 
into the anterior urethra 8 to 10 c.c. of a 1 per cent solution of stovaine 
with a syringe (Fig. 56). But this should be avoided so far as pos- 



TECHNIC OF URETHROSCOPY 



i i 



siblc, as stovaino causes an aiicinia of ihc iirdln-al iiiuffjsa Avliicli alters 
the uretliroseopic picture iiiateiially. [In America stovaine is not re- 
garded favorably for local anesthesia. Alypin 2 per cent is not toxic 
and does not lilancli the mucosa. For the anterior urethra, one dram 
of the solution is injected, and retained for about five minutes, when 
perfect anesthesia is ol)tained. For the deep urethra, two or three 
% grain tal)lets deposited by means of a Bransford Lewis tablet de- 
positor, will give most satisfactory anesthesia. — Editor.] 




Fig. 58. — The uretliroseopic tulie having iieen introduced, the obturator is withdrawn and the handle is 
attached to the collar of the tube '.lamp pointing downward). 

Operative Technic. — The uretliroseopic tube and its ol)turator, 
having been selected for the particular case, is sterilized and freely 
lubricated with sterile glycerin or jelly. The former, being trans- 
parent, has the advantage of affording a clear unobstructed yiqw of 
the urethral mucosa. The tube is gently introduced down to the mem- 
branous urethra; its passage lieyond this point is facilitated by mak- 
ing pressure Avith one liaiid over the liy))()gastriuin, thereby lowering 
the subpubic ligaments. 

Tlie introduction of the straight uretliroseopic tube into the pos- 
terior urethra has been reerarded bv some as difficult; some writers 



78 



CYSTOSCOPY AND URETHROSCOPY 



have even insisted on preceding the introdnetion of the tube by the 
passage of an armed filiform guide. But this is really unnecessary 
in the vast majority of cases. In point of fact, it is agreed that intro- 
duction of the tube shall not be attempted unless the canal is suffi- 
ciently large to accept it, for as has already been pointed out, urethros- 
copy is useful and worth while only under this condition. 

On the other hand, the ]Dosition of the XDatient is important. He 
should lie on his back, the buttocks resting on the edge of the table, 
and his feet resting in the stirrups. The operator seating himself 
between the patient's legs, slowly passes the instrument vertically into 
the urethia. AVhen the tip has reached the membranous urethra, the 




Fig. 59. — In the examination of the posterior urethra, the handle of the urethroscope is turned 
upward, the lamp also upward, to avoid the urethral secretions which gravitate down upon the lower wall 
of the tube. 

handle is depressed so that the tube lies horizontally, and with a little 
dexterity it passes easily into the deep urethra (Fig. 57). When all 
resistance has ceased and the-4;ube moves freely, we know that it has 
entered the bladder ; further evidence is offered by the escape of urine 
through the tube. 

The tube is now drawn forward gradually until the flow of urine 
ceases. The tip of the instrument is now in the deep urethra. The 
secretions of this part of the canal are now swal)bed with the cotton 
carrier and when the mucosa is fairty dry, the lamp is inserted (Fig. 
58) with the handle of the urethroscope pointing downwards. The tube 
is now rotated 180 degrees, so that the lamp rests on the upper sur- 



TECHNKi ()|.' nr.K/i'ii Koscoi'N' 



'!) 



I'ac*' of llic tiilx'. Ill lliis way, llic laiii|) Is inaiiilaiiMMl lii^li alioNc l!ic 
urclliral floor, g'iviiiii,' a heller illiiiiiinalioii, and it is kepi I'lom heijii;' 
ohscuTod coiitimuilly ])y (lie secrelioiis on llie nrellnal lloor wliieli 
should 1)0 studied carofully, aud which would he eiicounlenMl were 
the lamp not I'otatod iu this manner. 

Tho vorumontanum is visible below and can easily be freed from 
accmnulated secretions or blood by the cotton swal). This assures a 
clear and distinct view. Little by little the tube is di-awn forward 
and all portions of the canal thus br()U.L!,'lit under inspeelion of ilie 




Fig. 60. — Intraurctliral niani]]iiIatioii ; drying tlie imicnsa wiili cotton swabs. 

observer. The urethral mucosa can be distinctly iiisi)ected willi vo- 
markable clearness by this method, owing- to the clennsiuu- \\itli I he 
cotton SAvab. 

In the older ui-ethroscopes with inteiaial light, siicli as the Ober- 
laender, for exani])le, it was necessary to wit lid raw the light each 
time before the applicator could bo insiMied; willi this iiist lument, 
however, tho lamp may not only remain in its place witliiuit cansiug 
any iuconveuieuce, l)ut in addition, it serves to aid and ilhiminale \\\o 
necessary manipulation in the intei-ioi- of the tnhe. it is, therel'ore, a 
simple matter to apply caustics aud other theiapeiitic agents directly 
to the affected spot, owing to tiie direct \iew thus ohtainod (Fig. GO). 



PLATE III 

Fig. 1. — Glandular lesions of the anterior wall of the prostatic urethra, as 
seen through the urethroscope. All the infected glands of the prostate 
are seen vesiculated and have the appearance of frog's spawn. Under 
dilatation, all the prostatic vesicles burst and disappeared, and a 
cure resulted. 

Fig. 2. — Glandular lesion of the anterior surface of the prostate, seen 
through the urethroscope. Compare this picture -with Fig. 1, Plate I, 
which represents the healthy condition. 




Fig. 1. 




Fig. 2. 

PLATE III 



TECTTNIC OV riiKTI lltOSCOPY 81 

Contraindications to Urethroscopy. — Uretliroscopic examinations 
slionld not ])e made rocklossly in all cases of urethritis; in acute or 
recent infections the introduction of any instrument in an inflamed 
canal must be prohibited. This instrument may, therefore, be em- 
ployed only wIkmi there is no pain on urination, or during erections, 
and when the urine is fairly clear. Nor should the examination be 
made while the urethra is still sensitive or tender. 

Generally speaking, the uretliroscopic tube should never he used 
unless we are familiar ivith the urethral caliber. It is extremely un- 
wise to insert a urethroscoi^ic tube into a patient who has been seen 
for the first time. There is always the risk of being stopped by a 
small meatus or a stricture in the urethra, with the resulting pain and 
hemorrhage. Urethroscopy should also not be undertaken ivhile there 
are inflammator}^ complications of the posterior urethra, such as epi- 
didymitis, acute prostatitis, etc. Finally, as an axiom, the uretliro- 
scope shoidd never he employed in a caned which has not heen pre- 
viously studied and dUated. 

Concerning Adrenalin in Urethroscopy. — This is a valuable aid in 
urethroscopy, in cases in which there is an oozing of blood ^\'hieh 
renders the examination of a particular spot almost impossible. Swab- 
bing with cotton is of no avail, owing to the persistence of the oozing, 
and it may even increase the bleeding, in some instances. The em- 
ployment of adrenalin in these circumstances is strongly indicated. 
A cotton swab dipped in a 1:10,000 solution applied to the bleeding- 
spot will quickly stop the oozing. But the surgical principle of hemo- 
stasis must be applied; that is, the exact bleeding point must be iso- 
lated and treated with the solution. If the adrenalin is applied in 
haphazard fashion, it will probably be of little or no avail Avhatever. 

There is a decided disadvantage in using this medium, however; 
while adrenalin is a vasoconstrictor of a high order, a vasodilatation 
is produced just as soon as its ephemeral action has passed off, 
and this is capable of producing a secondary hemorrhage of an ex- 
tremely disagreeable character. On the other hand, this solution must 
be used only drop by drop, and should never be injected into the 
urethra with a syringe. Johnson, of San Francisco,' reported a case 
in this connection in Avliich hemorrhage followed a urethral dilatation, 
Johnson endeavored to stop the bleeding by filling the anterior urethra 
with a 1:4,000 solution of clilorhydrate of adi'ciialin. The i>aticiit siid- 
denh^ became livid and motionless and his eyes became glassy; this 
was followed by vomiting and complete collapse, feeble respiration, 
pulse hardly percepti1)le and the heartbeat inaudible. After a fcAV 
minutes the patient was revived wiili diriiculty through the use of 



82 CYSTOSCOPY AND URETHROSCOPY 

strong hypodermic stimulant injections. For three honrs he was 
nnable to stand on his feet. 

REPEREIsrCES 

iSigurta: Di uu nuovo appareechio portatile indepeudente per la produzione della luce el- 
letriea per uso endoscopieo, Atti della Societa Milanese di Mediciiia e Biologia, Milano, 
1908, iii, No. 5. 

2johnsou: Jour. Am. Med. Assn., Oct. 7, 1905, p. 1086. 



URETHROSCOPY OF THE NORMAL AND PATHOLOGIC 

URETHRA 

1. Urethroscopy of the Normal Urethra 

General Observations.— Before entering on a stndy of the nrethra, 
it is well to consider a few observations common to all portions of the 
canal. The consistency or thickness of the mucosa varies according 
to the individual to be examined. It is thinner and more delicate in 
individuals whose genital organs are small or atrophied ; while, on the 
other hand, it is firmer and denser in vigorous subjects. The color of 
the mucosa also varies considerably in different individuals, ranging 
in the normal state from a reddish gray to blood red, according to 
the extent of vascularization. 

The color differs also according to the caliber of tube employed. 
If a large tube is used, the pressure which it exerts on the mucosa is 
often sufficient to produce a distinct anemia and blanching of the 
mucosa. If the operator makes more or less pressure on one wall, he 
causes a localized paleness on that spot, which an inexperienced ob- 
server might regard as pathologic; but by moving the tube it is 
readily seen that the change in color is due only to the pressure of the 
tube on the wall. The local use of cocaine or stovaine will also jDroduce 
an anemia of the mucosa. 

A rather extensive experience in urethroscopy permits me to note 
a rather interesting phenomenon ; namel}^, that the color of the mucosa 
seems to correspond with that of the face of the patient. Very often 
in the course of a urethroscopic examination when I noticed that the 
urethral mucosa suddenly became white, I observed that the patient's 
face became white at the same time and that he was about to faint. 

Two distinct features of importance ma^^ be distinguished in every 
urethroscopic picture; i.e., the "central figure," and the mucous sur- 
face proper. The central orifice of the urethral canal constitutes the 
"central figure." Normally, the urethral walls are in apposition, so 
that its lumen is potential rather than real except while urine is pass- 



IJRETTinOSCOP^' OF XORMAL AND PATirOLOOIC URETHRA Ki 

iiii;- tlii'()ii,<;ii. When tlic cikIoscojx' is iiisci'icd, li()\\('V<'i', tii(; urothral 
walls separate symmetrically at the lower end ol' the instrument, 
presenting an appearance resenililing a Funnel, tin; neck of which is 
made up of the center of the ui-etliral canal and the sides are formed 
by the walls of the urethra prox:)er. 

This funnel is more or less distinctly defined according to the 
position in which the urethroscopic tube is held. AVhen the hold on the 
tube is relaxed the funnel effect is l)ut slighth^ visil)le; and when tlie 
tube is iDushed downward against the pressure of the hand, the mucosa 
is drawn or pushed into the lumen of the tube and the funnel sliape 
becomes still less marked and almost done away with entirely. But 
when the tube is drawn forward toward the meatus, the funnel be- 
comes deeper and better defined, and if in addition, pressure is made 
on the penile urethra with the free hand, a very long funnel will be 
created which may even assume the appearance of a true cylinder. 

There is a decided advantage in each of these methods of examin- 
ing the urethra. In point of fact, when the mucosa in the tube is made 
to stand out prominently by pushing the tube downward, certain local- 
ized areas may be examined with great clearness ; when, on the other 
hand, however, traction is made on the penis and on the urethroscope 
simultaneously, the lesions may be observed in profile. This method 
of examination is of consideral)le value when the purpose of tlie exam- 
ination is to discover small chronic glandular inflammations which i3ro- 
ject slightly into the lumen of the urethra. 

In order to see everything Avell, it is essential that all of these 
variations must be known to the observer. Similarly when a par- 
ticular spot is to be examined carefully, the tube may l^e inclined on the 
axis of the urethra and an eccentric view may be obtained, if the cen- 
tral figure is still visible ; but if the central figure has comxDletely dis- 
appeared, onl}^ the urethral walls Avill be seen. 

The aspect of this central figure varies considerably in different 
portions of the urethra. At the glans, it has the form of a little oval 
slit; in the penile region, it resembles a point; in the bulbous portion, 
it takes the appearance of a vertical slit ; and finally, in the deep urethra, 
at the level of the verumontanum, it assumes a peculiar aspect due to 
the prominence of the verumontamim (Plate I, Figs. 2, 3, and 4). 

The surface of the urethral mucosa presents a series of longitu- 
dinal folds or striations in the shape of wheel spokes. These folds are 
more or less marked according to tlic degree of stretching of the ure- 
thra and also according to the thickness of the tube employed. Tn the 
normal uretln-a they are quite well marked, but they undergo consider- 
able modification in pathologic conditions. 



84 CYSTOSCOPY a:n^d tjretheoscopy 

In the normal mucosa the color of these striations is a more or less 
Ihdcl red, the striations forming heantiful bright red ra^^s which merge 
gradually into the substance of the mucosa, which is of a light 3^ellow 
rose color. The surface of the normal mucosa is smooth and brilliant 
throughout and it becomes irregular and dull in the XDathologic state. 

The orifices of the lacunae of Morgagni are barely \dsible in the 
normal urethra ; when visible, they appear in the form of little points or 
needle pricks slightly dilated, and are situated on the upper wall of 
the urethra. Likewise, the glands of Littre are practically invisible in 
the healthy urethra, and often are passed unnoticed in an examination 
of the canal. We shall see later on, however, that they change mate- 
rially rmcler loathologic influences ; they become protruding, and con- 
gested, surrounded by a reddish zone, and easily visible. 

2. Urethroscopy of the Normal Anterior Urethra 

The central figure is practically the same in the entire anterior 
urethra, except that at the gians it has the form of a perpendicular slit, 
sometimes oval. In the pendulous portion, it has the appearance of a 
IDoint, which often becomes enlarged and takes on the appearance of a 
transverse cleft studded with little indentations. The longitudinal folds 
ax)pear like the s^Dokes of a wheel. They are more easily visible if a 
narrow tube is employed and less readily recognized when a thick tube 
is used. In the region of the glans, where the urethral mucosa is 
smooth, they are not seen ; they vary from four to six in number. 

Longitudinal striation due to vascular ramifications is more 
marked in vigorous subjects. The lacunji?^ of Morgagni are situated on 
the upper wall of the iDenile region. Their orifices look like little pits 
having a color similar to that of the adjacent mucosa. Normally, their 
walls are not elevated above the neighboring mucosa. The large lacu- 
nae, however, are easily recogniza1:)le, from the fact that they are V- 
shaiDed, the apex of the letter pointing do^\mward and the arms bound- 
ing the walls of the follicle (Plate VIII, Fig. 2). 

Littre 's glands exist in great numbers on the entire surface of the 
urethra. Normally they are not visible and become so only patholog- 
ically. Cowper's glands ox)en on the urethral mucosa through orifices 
which are rarely recognizable. Most often, they are obscured by the 
folds of the urethral mucosa. 

3. Urethroscopy of the Normal Posterior Urethra 

The tube having been introduced and the deep urethra cleansed 
mth a cotton swab, the lam]) is turned on and a distinctly characteristic 



UPiETHIlOSCOPY OF NORMAL AND PATHOLOGIC URETIIPiA 



85 



picture is o1)served (Plato I, Fig. 1, also Fig. Gl). Abovo, we encoun- 
ter tlic neck of tlio bladder, shaped like an iiiruiidil)uluni or funnel. 




Fig. 61. — Urethroscopic view of the "prostatic fosseltc." Normal aspect of the posterior urethra situated 
between the verumontanum and the neck of the bladder. 

From this i)oint the folds of smooth mucosa descend in regular and 
diverging series in the shape of a fan. The handle of the fan is above; 
the body of the fan is below. 




Fig. 62. — Anatomic view of the "prostatic fossette," comprised between the posterior margin of the 

verumontanum and the bladder neck. 

Withdrawing the urethroscoiDe gradually, the iDosterior aspect of 
the verumontanum comes into view. Immediately behind the verumon- 



86 CYSTOSCOPY AXD UEETHEOSCOPY 

tanum is a little fossette, or space, wliicli should always liave a tlior- 
ougli examination. This prostatic fossette [postmontane space — 
Editoe] should be explored methodically in cases of chronic urethritis, 
for it is very often the seat of chronic inflammations Avhich can not be 
seen or even susioected by any other method of examination. This 
space is well shown in Fig, 62. Anteriorly it is bounded by the idos- 




Fig. 63. — Xornial verumontanum, the orifice of the prostatic utricle not visible. 

terior wall of the verumontanum; posteriorly, it ends at the bladder 
neck ; laterally, it is bounded by the urethral walls. 

It has been maintained that this examination can not be per- 
formed properly with a straight tube, but this is not the case, for it is 
only necessary to deiDress the extremity of the tube slightly, seesaw 




Fig. 64. — Normal verumontanum, the orifice of the prostatic utricle visible. 

fashion by raising the handle and depressing the verumontanum. In 
this manner the posterior wall of the verumontanum can be readily 
examined. This done, the tu]3e is gradually and gently draA^^l forward, 
thus bringing the bod}^ of the verumontanum into view. Its usual 
appearance is well shoA^ai in Plate I, Figs. 2, 3, and 4. 



im;I'7I'iik()S('()|'\- oi' xoiimal and I'a riioLodic ri;i'7i"iii:A 87 

The Verumontanum. Tlic vci-uiiioiilaimin usually apjx'ars in the 
loriu oL' a spindle ('l()iii;atc<l froin hd'oi-c haekwafd ( I^'ii;'. (il^). A1 limes 
it takes tlie sliap*' of a lai'.^c pi-ojcclion hui.^Iii.L;' at llic lop; a1 oilier 
times it fills tlie eiitir<' luiucii of the uid liroscopic tube; occasionally 
only the anterior as]i('('l can he seen, and when the tube is di'awn for- 
ward somewhat further, i1 is seen diminislie(| in liei.i;'ht and bi-eadth 
and becomes continuous aiii<'i-iorly with ils frenum. Al limes llie pros- 
tatic uti'icle is not at all visible (Fi^'. ()3) or only sliglitly so; while 
at other times to the contrary, it is clearly perceptible to the eye (Fi^". 
64). All of these varied aspects are beautifully shown in the colored 
plates. 

Tn most instances the prostatic utricle is sin.<i,-le and situated in 
the median line, the orifices of the ejaculatory ducts remaininfi,- invis- 




Fig. 65. — Normal verumontanum, without a median prostatic utricle; the ejaculatory tlucts terminate lat- 
erally, giving the appearance of a diver's helmet. 

ible; but in many cases an arrangement quite different is observed. 
The utricle is not seen at the center, but the ejaculatory ducts are 
clearly visible, each orifice corresponding to the opening of an ejacu- 
latory duct situated laterally and the eiitiic veiumontanum closely re- 
sembling a diver's helmet (Fig. 05). The im})oi-taiice of the examina- 
tion and study of the verumontanum is exceedingly great owing to 
its intimate pathologic relationship with the seminal vesicles. This 
relationship is so close that the prostatic utricle well deserves the title 
which has been given to it; i. e., the ''mirror of the seminal vesicles." 
Above the verumontanum the ])icture changes sud(h'nly. The ure- 
thral nmcosa is ai'ranged in folds and pi'eseiits a chai'acteristic asjiect 
in the form of a swelling which ()ccu])ies the entire u])])e]- ])art oi* the 



S8 CYSTOSCOPY ASTD UEETHEOSCOPY 

nrethroscox)ic tube ; it forms a crescent, concave at the side, avMcIi sur- 
rounds the verumontanum. This fold is a very vahiable guide in esti- 
mating the sliape and size of the verumontanum. ^ 

As we move still further forward, the picture changes again. The 
anterior aspect of the verumontanum narrows little by little to the 
Avidtli of its frenum and completely disappears in the floor of the ure- 
thra. "We now reach the membranous urethra. The regular schematic 
appearance of this part of the canal presents a central point which is 
the lumen of the urethra and from which the striations radiate. As 
the tube reaches this portion of the canal, it is tightly gripped and 
moved about with some resistance, but as it is brought still further 
anteriorly the resistance diminishes and the tube moves more freely 
again. 

It is advisable to raise the handle of the tube gently as it leaves 
the membranous urethra, otherwise there is danger of the tube being 
throA\m ui^ward suddenly by muscular action, thereby causing the 
patient unnecessary pain. The observer now passes from the position 
indicated in Fig. 55 to that sho^^m in Fig. 54. 

The vast difference in the urethroscopic picture is now noted. 
The bulbous urethra gives its characteristic aspect. We see a vertical 
cleft very distinctly outlined. On either side are two smooth muscular 
projections diverging outward. This ]3eculiar vertical slit is produced 
by the lateral compression exerted at this point by the bulbous and 
ischiocavernous muscles. 

4. Urethroscopy of the Pathologic Anterior Urethra 

General Observations. — The lesions of chronic urethritis viewed 
through the urethroscope were first described in a masterful manner 
in 1893 by Oberlaender, and in a later work in collaboration with Koll- 
mann^ published in 1910. We may also note the important works of 
De Keersmaecker and Yerhoogen,' of AVossidlo,^ and finally in France, 
of Janet* and of Fraisse.^ 

Oberlaender following the evolution of the gonorrheal process dis- 
tinguished two distinct factors in the study of the chronic inflanmiatory 
lesions of chronic urethritis. The first is the soft infiltration {infiltra- 
tion molle) characterized macroscopically by a turgescence of the mu- 
cosa and histological!}^ by an infiltration of the submucosa ^^ith small 
cells, the entire process being accompanied by vascular dilatation. 

The second factor which succeeds the first in the evolution of the 
pathologic process is the hard infiltration [infiltration dura), which is 
characterized macroscopically by a special paleness of the mucosa, 
which takes on a yellowish gray color, and liistologicallv bv the invasion 



URETHROSCOPY OF NORMAL AND rATHOLOGIC URETHRA 89 

of tlio sul)inncosa by small ooiinoctivc tissuo colls -which .i^radually take 
the place oi" the enibryoiiic cells of sol't iiifilti'ation and eventually 
transform the submncosa into iibi-ous tissue. The presence of this 
fibrous tissue strangles the blood vessels, stops the circulation, and 
brings about this particular discoloration of the mucosa. 

The mildest degree of this type of infiltration corresponds to the 
large caliber stricture described by Otis, -while the severest degree con- 
stitutes the true organic stricture of the urethra. 

Soft infiltration accompanies and follows the inflammatory lesions 
of acute urethritis and is, therefore, found chiefly in the early periods 
of chronic urethritis. As a result through the evolution of the inflam- 
matory process, the soft infiltration is eventually replaced by hard 
infiltration. Though there is no doubt that both forms are absolutely 
dissimilar, not only nrethroscopically but also anatomically, they must 
in fact be regarded as successive phases of one and the same morbid 
evolution. Moreover, it is well to remember that both types can exist in 
the same urethra simultaneously. 

It is Avell laio-wn that chronic urethritis is peculiarly characterized 
by the presence of distinctl\^ localized areas of chronic inflammation. 
Each of these morbid processes can develop locally in an isolated 
fashion by itself. So that in a given urethra it is quite customary to 
see healthy mucosa alternate with portions attacked with soft infiltra- 
tion and even -with hard infiltration, as well. 

Before taking up these urethral lesions, it is well to point out the 
most frecjuent i)oints of localization of chronic urethritis ; i. e., the 
middle portion of the penile urethra, the penoscrotal angle, and the 
membranous region. Indeed, several distinct areas may be involved at 
the same time. 

Soft Infiltration. — There is no particular difficulty in introducing 
the urethroscope into a canal affected with soft infiltration only. At 
most the urethra may bleed slightly either during the passage of the in- 
strument or while the lesion is being swabbed Avith cotton. The general 
appearance presented by the urethra affected with soft infiltration is 
that of a hyperemic mucosa, inflamed and turgid. Usually it is smooth 
and glistening (Plate VII, Fig. 5). It is best compared, for purpose 
of illustration, with a mass of inflamed hemorrhoids. 

The color varies from dark red to blood red and '* cyanotic" rod. 
Soft infiltration is most often ioealizod in irregular^ disseminated 
centers, most commonly in the prostatic and membranous regions. 
These centers vary considerably in size, ranging from the size of a 
small gold chain link to several centimeters in diameter. The number 
of the foci is also varial)le; they may be single or more frequently 



90 ' CYSTOSCOPY ATTD URETHROSCOPY 

multiple, and in the vast majority of instances are separated from one 
another by intervening healthy tissue. Their shape is distinctly irreg- 
ular ; the margins are not well defined, but are fused with thewhealthy 
tissue surrounding them. 

The epithelium at first has a brilliant luster ; but when the lesions 
have persisted for a certain length of time, it desquamates or at least 
becomes thinner and more fragile. It then loses its luster gradually 
and becomes opaque and roughened. In places it may disaxjpear en- 
tirely, and the papillar}^ layer thus exposed begins to proliferate, giv- 
ing rise to little granulations analogous to but less marked than those 
which are encountered in skin wounds. These petty granulations ap- 
pear in the guise of little reddish irregular specks, the surfaces of 
which are red and bleed easily on contact. They are very numerous 
at the bulb. 

The longitudinal folds of the mucosa are materially changed. In- 
stead of the numerous folds which are usually found on the healthy 




W 

Fig. 66. — Kollmann's pipette, for aspirating the glandular secretions. 

mucosa, only two or three are seen, and these are but poorly outlined. 
They project into and even obstruct the lumen of the canal. The longi- 
tudinal striation is hardly visible; it is lost in the hyperemia and 
tmnefaction of the mass, the latter appearing only as a uniformly 
smooth surface. 

The central figure is almost always closed, so that the aperture 
can not be seen, even when the tube is being withdrawn. The lacunae 
of the Morgagni and Littre glands are always involved in soft infil- 
tration. The inflammatory process gives rise at first to an increase in 
the glandular secretion; their mucous covering is red and slightly 
puffed up. Their excretory orifices appear like red projections as 
large as a pinhead, forming a little tumefaction with raised and glassy 
l)orders. A mucous or purulent secretion may be seen escaping from 
these orifices; this secretion can be collected for microscopic examina- 
tion by means of the pipette devised for this purpose by Kollmann, of 
Leipzig (Fig. 66). The lacun?e of Morgagni form a projection at the 
surface of the mucosa which may attain the size of a small pea; or they 
may appear like a nodule, the size of a pinhead, on the top of which a 



IIItK'I'KltOSCOI'Y OK NOIt.MAI. AN'D I'A'I' 1 1 ( )L( )( ; IC I ' IlK'l' 1 1 i;A 



91 



lilllc ()])('iiiii,i;' may somcliincs lie seen, '^riic (mIj^cs of ilic Inllci' ai'c 
swollen and iraiisluccnl and ;i mucous or purulent sccrcliou may bu 
seen pi'ol rudiii.i;' from llicir ori (ice. 

Pa])illomala may oricii accoinpanN' soft iiirilti'alioii. (Vuall>' small 
and isolated, they may, nevertheless, he Jon<»-, thin and rra<;ile, or short 
and tliick, ])ro,iectinii,' into the lumen of tlie iiretliroscoi)ic tul)e. They 
usual 1>' resemble the type so often seen on tlie prepuce. They are pro- 
duced as tlie result of the excessive proliferation of the mucous derma 
where tliey are exposed hj the desquamation of the epithelium. 

Occasionally they are gathered together in little liea])s, e\-en to the 
point of ohstructing the lumen of the canal. Their favorite site is in 
the hulhous urethra or near the verumontanum. In one case, Ober- 
laender saw them extend over the entire length of the urethra and even 
invade the bladder. Ch-iinfeld described these papillomata in his work 
on endoscopy." Several of these are shown in Plate IT, Figs. 1 and 2. 

In the case of a young man aged twenty-six years, referred to me 
by TIartmann, Avitli a chronic urethritis of two and a half years' dura- 




Fig. 67. — Little polypus situated at the bottom of a lacuna of Morgagni. 



tion, urethroscopy revealed a large lacuna of Morgagni on the anterior 
wall of the penile urethra near the root, partially destroyed. Two 
floating shreds were attached to the bottom of the lacuna. On careful 
examination, a little budding polypus Avas seen near the attachment of 
the shreds, which constituted the debris of the destroyed lacuna (Fig. 
67). 

Hard Infiltration. — As opposed to what occurs in soft inliltration, 
the introduction of a urethroscopic tube in a urethra affected with hard 
infiltration, presents a degree of resistance more or less accentuated ac- 
cording to the amount and character of the infiltration. At tinu^s this 
resistance is so marked as to obstruct the introduction of even the 
smallest tu1)e. In such cases we are dealing with a tight organic 
stricture. 

Lack of resilience is characteristic of all hard inliltralions: this 
being due to the progressive transformation of tlie cell infiltration in 
the sui-rouiidiug tissues. In ])roi)ortion as lliis adjaeeiil tissue becomes 



PLATE IV 

Fia. 1. — Glandular lesions of the anterior portion of the prostate, as seen 
by the urethroscope. The infected prostatic follicles instead of being 
vesicular and like the spawn of a frog, as in Fig. 1, show them- 
selves here in the form of real little abscesses. 

Fig. 2. — Little polypus situated on the apex of the verumontanum. 

Fig. 3. — Pathologic aspect of the anterior surface of the chronically in- 
fiojmed verumontanum. "When a verumontanum is seen through the 
urethroscope so deformed and inflamed, it is reasonably certain that 
an accompanying inflammation of the seminal vesicles exists. "The 
iirethroscopically pathologic ve]-umontanum is the mirror of the seminal 
vesicles. ' ' 





Fig. 1. 



Fi«. 2. 




Fig. 3. 

PLATE IV 



URETHTIOSCOPY OF XOIIArAL AXD IWTI lOLOCIC URETHRA 93 

more douse and coiiipacl, llic l)loo(l ciiculation of tlie mucosa is altered 
and tlie tissue loses its normal color and elasticity. In extreme degrees 
of hyperplasia oC llic adjoiiiiiii;- tissues, llic mucosa becomes hard and 
unj'ielding. 

The .i^encral appearance presented by a mucosa involved in hard 
infiltration is characterized by a distinct diminution in color from 
])ii,<;ht red to ])ale i^ink (Plate Vl, Fig. 2, and Plate VIT, Fig. G). The 
color of the nmcosa at first pale and anemic, appears in the most severe 
cases grayish or even yellowish, and later on, in cases of true stricture 
it becomes uniformly grayish white. These various modifications in 
color depend on the more or less active proliferation of cells in the sur- 
rounding tissues. As it increases in thickness and density, this infil- 
tration brings Avith it more or less marked changes in the blood circula- 
tion which l)ecomes impeded in varying degree. This fibrous tissue 
chokes the vessels and thus obstructs the blood stream. It is thus read- 
ily seen that in cases of true stricture, — those in which the urethro- 
scopic examination can not be made without previous dilatation, the 
mucosa appears uniformly pale yellowish in color with an appearance 
generally resembling gangrene. 

As in the case of soft infiltration, the site of the trouble is dis- 
tinctly localized; the most common sites are the midpenile region, the 
penoscrotal junction particularly, and the membranous region. Histo- 
logically the fibrous tissue is found principally near the glands; but it 
may also appear more rarely, in the mucous tissue itself. This tissue 
then manifests itself in the form of little cicatrices about one centi- 
meter in extent or in the shape of little stars from one to two milli- 
meters in size. 

Degree oe Hard Ixfiltratiox. — The intensity of the infiltration be- 
ing variable in degree, the exact measure of its extent is extremely dif- 
ficult, if not impossible, to determine. Oberlaender distinguishes three 
degrees: 1. That in which the canal i^reserves its normal caliber. 2. 
That in which the canal though. narroAved still admits a Xo. 23 ure- 
throscopic tube. 3. That in which a Xo. 23 tube can not l)e introduced. 

Thougli this classification is purely arbitrary, nevertheless, it is 
one which can be readily applied with considerable satisfaction. A 
more simple though less exact classification can be adopted which takes 
into consideration but two types: mild types corresponding to the large 
caliber stricture of Otis, and the more serious type, or true stricture. 
In reality there are so many transitional forms, which develop froni 
the simple mild type to the real organic stiicture, that it is difficult to 
establish clean-cut and well-defined classifications. 

The e])i11i('liuiii in hard innitralion ])r('sents ]inth()h)gic changes 



94 CYSTOSCOPY AXD UEETHEOSCOPY 

wliicli are due to its defective nutrition. In tlie first degree infiltration, 
the epitlielium loses its luster and transioarency and takes on a dull 
appearance. In a more accentuated degree of infiltration, a-^process 
of desquamation takes i^lace due to a proliferation of tlie epitlieliun]. 
these phenomena being found especially marked at the point most dis- 
eased. The epithelial surface of the urethra then appears irregularly 
roughened, presenting small projections of about a millimeter in height 
surrounded by rather large deiDressions which bleed easily on contact. 
The epithelial proliferation results in the formation of little specks, 
fairly ^vell marked, generally round and of peach gray color. They are 
of various sizes; sometimes very small, about the size of a pinhead, be- 
ing barely distinguishable from the surrounding mucosa: occasionally 
they are thicker by several millimeters, being about a centimeter in 
length and standing out prominently from the adjacent tissues. How- 
ever, instead of producing these small spots, the proliferation may ex- 
tend contiguously to more than half of the urethra. Li such event, a 
corneous infiltration of the urethral epithelium is the result and we 
have to deal with a thick, proliferated surface Imown as pachydermia 
or leucoj^lakia. 

In these cases the mucosa becomes dull, grayish in color, with an 
occasional spot showing the original rose color of the nmcosa. The lat- 
ter looks as if it were covered with a layer of gray powder. 

Urethral leucoj^lakia becomes localized usually in the form of 
plaques of varying extent with regular edges; they are easily distin- 
guished by their lustrous white, yellowish white, or grayish white color. 
Their surface is not smooth, but granular and ''angry." The placpies 
are oval in outline with their major axis directed lengthwise Avith the 
urethra. AVhen they are rubbed with a cotton swab it is seen that they 
are rather adherent. The superficial layers may be easily detached and 
then the deeper mucous layers will appear dark red, dull, and wrinkled 
and do not bleed easily. 

The longitudinal folds of the mucosa diminish considerably in 
the course of hard infiltration, and may even disappear entirely in the 
serious cases which terminate in stricture. Urethroscopically the ure- 
thra assumes the appearance of a rigid j^ipe which remains open Avhen 
the uretlirosco23e is withdrawn, due to the fact that it is a tissue with- 
out elasticity with stiff and smooth walls. The central figure is nearly 
always transformed into a funnel witli deep and rigid walls. In true 
stricture this funnel may measure one to two centimeters in depth. 
The picture is then absolutely characteristic. The urethral walls, re- 
tained by the fibrous tissue which surrounds them, do not come in con- 
tact Avitli one another as in the normal state, thus creating a funnel, or 



ui:i-:thi;osc()Py of xormal and PATiior/Kiic i'iietiira v.) 

better still, a tunnel Avitli smooth pale walls of the ay)])arent consist- 
ency of cardhoai'd. The lesions observed in hard infiltration are well 
sliown in Plate VI, Fift". 2. 

Glandular and Lacunar Lesions. — Tlie lacuna' of Moi'.f;a.t>,ni and tbe 
glands of Littre arc always attacked in \-arying' def:,-ree in liai'd infil- 
tration. Ag-reeing- witli Oberlaender, we may distinf;nisli two forms, 
(liiitc dilTci-ciit from cadi other: (A) The excretory diu-t remains pat- 
ent, and in this case the contents of the gland can i-un off and escape; 
this is called the "glandular" tyi)e. (B) The excretory duct becomes 
obstructed by compression from the neighboring tissues or by retrac- 
tion of its own walls; the secretion ])roducts are then retained and ac- 
cuimdate in the follicle, thus transforming it into a little cyst. Tliis 
is known as the "follicular" or "dry" type. This term "dry" is aj^- 
plied because of the appearance of the mucosa deprived of its glands; 
but it is accompanied almost invarial)ly by a more or less purulent and 
tenacious discharge. 

(A) In the "glandular" form the orifices of Littre 's glands appear 
enlarged and surrounded by an inflammatory ring. The orifice has the 
appearance of a crater and often gives forth a watery secretion. On 
gentle pressure of the extremity of the urethroscopie tube the lips of 
the orifice will often gape and a purulent and sometimes a clear liquid 
will emanate from them. Occasionally these orifices attain enormous 
size and the pressure of the examining tube will produce a veritable 
' ' shower. ' ' 

Morgagni's lacuna:' likewise present somewhat similar changes 
(Plate VIII, Fig. 3). The edges of their orifices assume a crater-like 
mouth, from which a mucous or purulent secretion oozes. If on the 
other hand the. perilacunar infiltration is very highly developed, the 
excretory ducts of the lacuna? project above the level of the mucosa 
and appear in the visual field in the form of little red j^rotuberances. 
Where dilatations have already been in.-^tituted, it is not imusual to 
see the glandular or lacunar orifices which are enormously enlarged, 
split apart with cracked walls. This condition mav explain the fre- 
quent exacerbations which frequently follow tlie fir^t dilatations. 

Nor is the following history unusual in these cases: A patient ])re- 
sents himself with a very slight discharge, sometimes nothing more 
than the "morning drop." The urine being clear even in the first glass, 
and there being neither pain nor any other contraindication against 
the urethral examination, the physician introduces the bougie or some 
other metallic instrument into the urethra in oi'der to determine the 
presence of ]K:)ssil)le centcfs of indui-ation. Two days later the ])atient 
returns in sui'])risc with an abundant <lischarge which coutains numer- 



96 CYSTOSCOPY AND URETHROSCOPY 

ous gonococci. Occasionally in the midst of recriminations addressed 
to the physician, the latter is accused of having produced the contam- 
ination by the use of infected instruments. In reality the tru.e expla- 
nation of the occurrence is anything but that, and very simple for any 
one who is familiar with urethroscopic investigation. 

When observed through the urethroscope, Littre's glands and Mor- 
gagni's lacunae often appear in the form of little cysts having rather 
thin walls. These little cysts may harbor gonococci for a very long 
period of time, and so long as they are not touched, the microbes may 
remain shut up within their thin walls ; but it is readily seen that when 
an instrument is passed into the canal and causes the cyst walls to 
burst, the gonococci s|)read themselves over the urethral mucosa and 
infect it over again. 

(B) In the ''dry" or ''follicular" form, as a result of the pressure 
exerted by the invasion of the adjoining infiltration, the excretory 
ducts of the glands are closed and the glands themselves obliterated 
in such a fashion that they are thus transformed into little subepithelial 
cystic cavities filled with a colloidal substance. These glands are at 
times transformed into real little purulent cysts which may be dissem- 
inated or grouped together into one or more heaps. 

Some very characteristic views of these lesions when the glands 
have been invaded by the infection may be seen on Plate VIII, Figs. 1 
and 2. 

In these ilhistrations, the subject was a young- sergeant major, twenty-five years of age, 
stationed in Paris. He had a discha,rge of fifteen months' duration for wliich irrigations 
and injections were of no avail. Clinically there was nothing but a slight discharge; wdiile 
the clear urine contained but a few filaments limited to the first glass. The urethra accepted 
a No. 21 b'ougie easily. Inspection of the penile urethra through the urethroscope resulted in 
the discovery of a series of numerous little white spots which gave the mucosa a granular 
appearance resembling a flower bed of purulent whitish points. Individually each one of 
these points was very small, but there were many of them; each one represented an inflamed 
Littre's gland filled with purulent contents. 

Considering the infinite number of affected glands, it was impossible to dream even of 
attacking them singly. It was decidedly more rational to treat them locally but en tloc. 
This was accomplished by gross dilatation with the Kollmann straight dilator. In two months 
there was a great improvement, but he was not yet cured. Another urethroscopic examination 
was then made, and revealed an exceedingly interesting state of affairs : At the penile urethra 
the mucosa had recovered its normal appearance, and the many little purulent cysts had dis- 
appeared owing in all probability, to the fact that the maximum amount of dilatation had 
been accorded this portion of the urethra by the complete separation of the arms of the 
Kollmann dilator. On the other hand, in the remaining portion of the urethra nearer the 
meatus which had not received so thorough a dilatation, tlie little pus-bearing cysts were still 
visible as before. 

The disappearance of a large numl)er of these purulent cysts through dilatation had 
brought about a notable improvement, but the cure could not be complete since the former 
condition had not been entirely removed. However, dilatation at the only points which still 



URETHROSCOPY OF-' NORMAL AND PATWOIAHWC URETHRA 97 

roniiiiiicil inl'cctcd i-i'sull<'i| in icsf (iiiii;; tli<' niucnsii [o its iioiniiil ;iii[ii';naiic(' iind wilii it gave 
till' patiiMit a perfect cure. 

These cysts (Plate VII, V'v^. '.]) may Ix' iiiiu-li lnr,i;('i- in si/c so llial 
tliey may pi'oject into tlie luiiieii of tlio iircitliral canal. They may burst 
under the eye of tlie observer hy the mere jjressure of the uretliroscope, 
inundating the uretliroscopic fiehl with their contents. 

The following is a case Mliich is not at all rare, as T have observed 
it several times, i)articnlarly in the case of a patient of Dr. Chenrlot. 
This man, twenty-six ^^ears of age, with an attack of urethritis of 
one and a half years' duration, had a numher of these cysts throughout 
the entire penile urethra. Methodical dilatation succeeded in causing 
the comjDlete disappearance of the lesions and the patient was entirely 
cured. 

I have encountered a still more typical case in which Littre's 
glands were changed into cysts similar to that illustrated in Plate VIT, 
Fig. 3. The historj^ of the case is as follows: 

The patient was a young man of twenty-iive, who had had a discharge for eleven 
moitths. Examined microscopically it was found to contain only leucocytes and cells. The 
urine was clear, but contained large heavy shreds limited to the first glass. The urethra, 
though presenting spasmodic resistance, was, nevertheless, absolutely free to No. 20. A series 
of silver nitrate instillations produced almost no result. Urethroseopic examination of the 
anterior urethra showed, in the midpeiiile portion, a considerable number of enlarged Littre's 
glands making a slight projection into the lumen of the .urethroscoi^e and apparently covered 
over by a fine whitish cuticle. One of these glands was quite large and distinctly ajDpeared to 
be a typical cyst. This is shown in the picture above referred to. 

Methodical dilatation of the anterior urethra with the Kollmann dilator was made 
over a period of three months. At tlie end of that time No. 44 had been reached without 
untoward incident and the patient had no longer any trace of discharge. The urine was 
clear and without shreds. Finally, a urethroseopic examination demonstrated the complete dis- 
appearance of all the cysts in the penile urethra and an absolutely normal mucosa in that 
portion of the canal. 

Numerous cases are encountered of the dry or follicular variety in 
which the excretory ducts of Littre's glands are obliterated, but in 
which, nevertheless, the glands still project through the nnicosa and 
are consequently still visible through the urethroscope. Quite numer- 
ous also are the instances in which the proliferation of the urethral 
epithelium and of the surrounding infiltration at the mucous surface is 
so great that the glands are forced back into the deej^er structures. 
These are the cases, and they are by far the worst, which offer the 
greatest resistance to treatment, and are the most difficult to cure. 

Palpation of the urethral mucosa stretched over a Benique sound 
gives very exact and important information in these cases. Indeed 
when the sound lias Ixhmi insci-lcMl into llic iircUii'a, if the lower wall 
of the urethra is ])alpated, many very clear small pi'ojections will ol'ten 



98 CYSTOSCOPY AND URETHROSCOPY 

l)e discovered. These are usually separated from one another, rounded 
like little cysts, and vary in size from that of a millet seed to a hemp- 
seed. At times they may attain a size approximating a hazislnut, or 
even a walnut. They may rupture externally and ultimately result in 
a urinary fistula. 

Having observed the exact location of one of these little projec- 
tions in the urethra with the sound, the urethroscope is introduced and 
the appearance of the mucosa at that particular point carefully studied. 
By inclining the tuhe laterally so as to put the mucosa on the stretch, 
nothing more than a smooth mucosa with few if any glandular orifices 
visible Avill sometimes be seen. This fact proves that the gland has 
been comi)letely obliterated and that it does not any longer communi- 
cate with the mucosa. 

The following case is absolutely typical of these conditions: 

A young externe of the Paris liospitals, twenty-four years old, contracted a gonorrhea 
and had been treating it for three months. At the end of that time, there was no discharge 
except a slight morning drop. When he came to me on October 5, 1903, he complained of 
having noticed for three weeks past, a little tumor situated on the lower surface of the 
urethra about five centimeters from the urinary meatus. This little tumor, at first the size 
of a pea and of a consistency of a lead shot, had suddenly increased in size during the pre- 
ceding six days and had attained the size of an olive. The pressure produced by this swell- 
ing had caused edema of the foreskin; rupture of the mass with a subsequent urethral fistula 
seemed inevitable. 

In the presence of these well-defined sjmiptoms I decided to make an examination with 
the urethroscope. Tlie tube having been introduced rather deeply and withdrawn gradually 
I was enabled to recognize a distinct point which indicated that I had reached the tumor. I 
noticed this curious fact, — that w^hile the swelling was as large as an olive and bulged clearly 
and distinctly externally, it projected very slightly if at all, into the urethroseopic tube. Bring- 
ing the tube to the level of the tumor, I cut the mucosa deliberately with a small Kollmann 
knife and plunged the blade into the swelling. In spite of a rather large incision, nothing but 
blood appeared. I then fixed the tube and the penis with one hand, and made pressure firmly 
on the tumor with the other hand, and squeezed it quite vigorously. All at once I saw a 
slough of flimsy stuff shoot forth which closely resembled the slough squeezed out of a 
furuncle. Tlie tumor diminished in size slightly for the moment but it was still quite large 
and presented a fibrous shell of great resistance and toughness. 

The after-effects of the operation were quite uneventful. The edema disappeared some 
days afterwards, and the patient was soon able to commence methodical dilatation of his 
anterior urethra with straight sounds. This dilatation was pushed up to No. 60 Benique. I 
saw the patient five months later, i. e., in March, 1904. He then no longer had any discharge 
and in place of the tumor nothing could be felt except a little fibrous core about the size of 
a hempseed. 

This case is interesting in more than one respect: It teaches the 
following: 1. That when the glands have lost their communication with 
the surface of the urethral mucosa, urethroscopy gives no information 
as to their location and condition. 2. That the contents of these fol- 
licles is not fluid, but, on the contrary, is made up of a slough similar to 
that of a furuncle. 3. That the fibrous infiltration surrounding the 



URETHROSCOPY OF NORMAL AND PATHOLOGIC URETHRA 99 

glandular walls constitutes tlie essential cliaracteristic of these cysts. 
4. That it is easy, with the aid of the urethroscoije, to attack these 
glands surgically when they threaten to suppurate. In this way, spon- 
taneous rupture externally might be avoided and thus prevent the de- 
velopment of a consequent urinary fistula. 

The excretory ducts of the lacunae of Morgagni also may become 
obliterated and eventually become choked up with their contents. The 
urethroscopic appearance is absolutely typical. The glandular orifices 
are barely seen, if at all. Here and there instead of a lacunar orifice 
a small grayish or yellowish depression is noticed indicative of a closed 
follicle and which resembles a little button about the size of a millet 
seed. These are the follicles which can be felt on external palpation 
of the urethra. 

I have had a case of this kind (Plate VII, Fig. 4) in which 
there was an apparent obliteration of a lacuna of Morgagni. It oc- 
curred in the case of a man, twenty-nine years of age, who had had a 
chronic urethritis for a year, characterized by a urethral discharge and 
multiple points of infection; i. e., chronic prostatitis, hard infiltrations 
in the perineal region, and glandular and lacunar lesions in the penile 
urethra. On the upper wall of the urethra, urethroscopy revealed a 
small, smooth oval projection about as large as a grain of corn cov- 
ered over with a yellow mucosa and presenting only some reddish 
striations. 

Dilatation of this lesion, even with the straight Kollmann dilator 
up to No. 42, produced no ai^preciable effect and its appearance after 
treatment was practically the same as before it was begun. Tavo or 
three applications of Kollmann 's electrolytic needle quite close together 
sufficed to bring about a cure at one sitting; after this application, not 
a single trace of the lesions could be observed. 

It is not rare to find the glandular and dry varieties of hard infil- 
tration in the urethra at the same time. This constitutes the ''mixed" 
type. Exceptionally this mixed form is found at the very beginning 
before any treatment has been instituted. Most frequently it is ob- 
served when the dry variety is treated by dilatation; in such cases the 
cysts open and become atrophied or destroyed; the excretory glandular 
ducts that have become free open externally and gradually we thus 
pass to the "mixed" and subsequently to the glandular type. 

REFERENCES 

lObcrlacnder and Kollmann: Die clnonisclie Gononhoe (lev mannlichen Hai'niolirc, Leipzig, 

Georg Thicm, ed. 2, revised, 1910. 
-De Keersmacckcr and Verhoogen : L'ututritc clnonique d'origine gonococcique, Bruxelles, 

Lamertin, 1898. 



100 CYSTOSCOPY AND URETHROSCOPY 

^Wossidlo: Die Gonorrhoe ties Mamies, Leipzig, Georg Thiem, ed. 2, 1909. 

4Janet : Ann. d. mal. d. org. genito-urin., 1891 ; Endoseopie uretrale, iu Lecons cliniques de 

Guyon, Paris, 1903. 
EFraisse: Gonorrhee chrouique de I'homme, Paris, Maloine, 1910. 
sGriinfeld: Die Endoseopie der Harnrohre und Blase, Deutsch. Chir., von Billroth und Luecke, 

Lieferung 51, 1881. 

5. Urethroscopy of the Pathologic Posterior Urethra 

In all cases of chronic urethritis it is absolntely necessary to ex- 
amine the entire posterior urethra and not to limit the examination 
to the anterior surface of the verumontanum ; the entire prostatic fos- 
sette [postmontane space] beginning with the neck of the bladder must 
likewise be examined and studied thoroughly. 

Clinically this particular portion of the canal does not present any 
special symptoms; nevertheless, it is often surprising to see lesions of 
the posterior urethra that pass entirely unnoticed even by competent 
physicians and which can not be discovered by any other means than 
the urethroscope. Very often when the patient does not complain of 
any special sensation on the part of the prostate and when his second 
glass of urine is clear without shreds or filaments; when the rectal ex- 
amination does not disclose any marked inflammation of the prostate 
and when even the most energetic massage of the prostate brings forth 
but very little prostatic secretion and this, almost normal, — even in 
these circumstances, where everything combines to force the conclusion 
that the posterior urethra is normal, such may not be the case. In 
point of fact, a urethroscopic examination of the posterior urethra 
often reveals the fact that well-marked lesions exist in the posterior 
urethra which, properly treated, will bring about a complete cure in 
cases hitherto believed to be almost incurable. In these instances, if 
chronic prostatitis is not responsible for the lesions, then surely chronic 
posterior urethritis must be the etiologic factor. 

In an interesting article, Wolbarst, of New York,^ has also justly 
insisted on the necessity of examining the verumontanum with the ure- 
throscope in all cases of chronic urethritis. In his opinion, it is essen- 
tial in all cases of spermatocystitis to treat, not only the seminal ves- 
icles, but also to treat thoroughly the verumontanum and the ejacula- 
tory ducts by means of the urethroscope. This author has published 
reports in which he demonstrated the fact that treatment of the sem- 
inal vesicles alone is not sufficient to bring about a complete cure and 
that it is absolutely necessary to examine and treat the verumontanum 
locally as well. 

The local urethroscopic treatment which he recommends is the di- 
rect application of a 10 per cent solution of silver nitrate or dilute 



URETHROSCOPY OF NORMA!. AND PATItOI/JGlC URETHRA 101 

tincture of iodiii; also applications ol' llic galvaiiocautci-y and Oudiii's 
jiigli frequency current (sparking). 

Soft infiltration is the most frequent lesion encountered in pos- 
terior urethritis. The mucosa is hyperemic, congested, and bleeds 
easily on tlie slightest contact. The verumontanuni involved in soft 
infiltration is dark red in color, swollen, and increased in size. It takes 
on a smooth ajopearance and becomes distorted in shape. The orifice 
of the prostatic utricle is open-mouthed, inflamed, and gives forth a 
nmcous or purulent secretion. Very often the swelling of the verumoii- 
tannm is so pronounced that this orifice as well as those of the ejacula- 
tory ducts, is lost in the thickened mucosa, and remains hidden from 
view. When these orifices and those of the prostatic follicles can be 




Fig. 68. — Urethroscopic lesions of the prostatic fossette, behind the verumontanuni. 

seen, they appear red, swollen, and surmounted with overhanging 
margins. 

Laterally, the ejaculatory orifices may be seen occasionally, more 
or less filled with pus. Thus in a case of left chronic epididymo- 
orchitis of gonococcal origin, I saw pus emanating from the left ejacu- 
latory duct; above, was the verumontanum, very much congested and 
displaced considerably. The membranous region, congested and even 
cyanosed comiDletely loses its luster; its folds become larger and more 
swollen and the nmcosa projects into tlie urethroscopic tube like a her- 
nia. It is quite customary to find the mucosa of the posterior urethra 
markedly swollen and manifesting itself in the form of bullous edema, 
concentrated more or less, and bleeding readily (Fig. 68). 

The prostatic follicles are very often the seat of chronic inflam- 
mation; their orifices often appear red, swollen, and sui'rounded with a 
projecting and overhanging margin. Coldschmidt has justly compared 



102 CYSTOSCOPY AXD UEETHEOSCOPY 

them to frog's eyes. At other times the}^ appear like little iDurnlent 
masses adjoining one another taking the form of little white buttons, 
often acuminated and simulating boils. It is well to note that this 
chronic inflammation of the iDrostatic follicles not only lies behind the 
verumontanum on the inferior urethral wall, but also on the anterior 
superior wall of the urethra, as is well shown in Figs. 68 and 69; it 
may likewise be observed in the lateral gutters or grooves situated on 
either side of the base of the verumontanum. 

For this reason the examination of the posterior urethra with the 
simple straight tube seems to give results infinitely preferable to those 
obtained with instruments designed specially for the posterior urethra. 
With Goldschmidt 's instrument, for examiDle, the anterosuj)erior wall 




Fig. 69. — Glandular lesions of the anterior surface of the ijrostate, seen with the urethroscope. 

of the prostatic urethra can not be examined Avithout great difficulty; 
in using this instrument, therefore, distinct lesions of the posterior 
urethra might be entirely overlooked. 

The following rejDort of a case of chronic jDosterior urethritis, with 
gonococci in the prostatic focus, is of particular interest in this con- 
nection : 

A man, forty-four years of age, referred to me by Portalier, had an attack of gonorrhea 
ten years previously wliich was treated simply with irrigations of permanganate. For ten 
years he had not noticed any apx^reciable discharge. Suddenly on May 6, 1910, the patient 
developed a profuse discharge containing typical gonococci. Greatly astonished by the ap- 
pearance of the discharge, he at once suspected his mistress and requested me to examine her. 
On two different occasions the most careful examination of the young woman was made, and 
notwithstanding the greatest care, I could not discover any possible infected focus which might 



URETHROSCOPY OF NORMAL AND PATHOLOGIC URETHRA 103 

harbor gonococci. The examinations included a uretliroscopic examination of the urethra, 
examination of the paraurethral glands, Bartholin's glands, the posterior vaginal cul-de-sac, 
and the cervical neck, which was scraped with a platinum loop. The rectum was also exam- 
ined and found entirely normal. In a word, the young woman seemed absolutely healthy and 
free from all gonococcal infection. 

The problem was to discover the origin of this mysterious infection. After some days 
of irrigation with permanganate, the discharge disappeared gradually and dried up completely. 
The urine, at first turbid, slowly cleared up to such an extent that a uretliroscopic examina- 
tion could safely be undertaken on May 27, twenty-one days later. To my great surprise, 
I found that the canal was perfectly normal behind the verumontanum up to the vesical 
neck; but at the verumontanum and in front of it there were well-marked lesions of soft 
infiltration. At this point, examination showed bullous edema, little polypi and polypoid 
forms in great abundance, together with an edematous thickening of the mucosa. The bulb 
and the penile urethra were apparently perfectly normal. It appeared then as if this was 
a manifestation of a very old chronic posterior urethritis which had permitted the gonococci 
to remain latent for a period of ten years and which suddenly reappeared at the end of that 
period. 

Gross dilatation of the urethra, at first with Benique sounds then with Franck's three 
armed dilator soon resulted in a complete cure of the patient. Urethroscojoic control was in- 
stituted after the application of Franck's dilator, and gave positive proof of the complete 
disappearance of all the lesions. 

Another instance of the same kind is also quite characteristic: 

A man of forty-five showed a discharge containing gonococci for six months. He had 
been treated by Wormser with urethrovesical irrigations of permanganate followed by gradual 
and methodical dilatation of the urethra with curved sounds up to No. 56. At the same time 
he had had an acute inflammation of Tyson's gland which was incised externally and com- 
pletely disinfected. In spite of this scientific and methodical treatment, the patient showed 
a recurrence of the discharge with gonococci as soon as the irrigations were suspended for a 
short time. It was therefore believed that there existed somewhere a permanent gonococcal 
focus. 

To discover the location of this focus, Wormser sent the patient to me on June 6, 1910. 
Examination of the urethra stretched over a straight Benique sound gave evidence o.f the 
presence of enlarged Littre glands; the prostate presented only minor changes; CoA\'per's 
glands and the seminal vesicles were ajDparently normal; the epididymes showed no evidence 
of a previous inflammation. 

Urethroscopy showed a normal anterior urethra, but the posterior canal revealed a num- 
ber of well-defined lesions. These consisted of little white vesicles very well marked, which 
lay just above the verumontanum. "When they were touched with a cotton swab they did 
not become detached and the swab slipped over them without their being ruptured. In view 
of these findings, I recommended that Wormser continue the treatment which he had so 
well begun and maintained, and continue the dilatation still further. The patient was then 
dilated up to No. 60 Benique. 

Four days later, however, the irrigations having been temporarily suspended, the dis- 
charge reappeared and was again found to contain gonococci. I examined him again 
urethroscopically on July 1, 1910, and was able to note that the lesions which I had observed 
near the verumontanum were still present and had not been changed at all. This latest re- 
currence was then easy to account for. In agreement with Wormser I began dilatation with 
Franck's dilator, pushing it to its extreme limit, this being attained on July 13, 1910. 

Following this treatment, the patient having gone six days without a permanganate 
irrigation, or any other treatment, he wrote me that his condition at the time was quite 
satisfactory, that there was no relapse of the discharge and tliat his urine was clear. The 
dilatation had seemed to produce the desired effect, and the focus which had harbored the 



PLATE V 

Fig. 1. — Curious patJwlogic aspect of the verumontanum. The prostatic 
utricle instead of being placed on the anterior surface of the verumon- 
tanum is detached and thus forms a distinct pocket. This case, ob- 
served in a man thirty-one years of age, referred to me by Gaston 
Alexandre, is especially interesting by reason of the sterility which 
was the inevitable consequence of this pathologic condition. This pa- 
tient, who was anxious to have children, found it impossible to pro- 
create; for at the moment of ejaculation the semen accumulated in 
the j)Ocket of the prostatic utricle and could not be projected forward, 
the seminal fluid oozing out some minutes later through the urethra. 

Fig. 2. — FathoJogic aspect of a chronic inflammation of the verumontanum in 
a case of chronic spermatocystitis. 

Fig. 3. — Unusual appearance of the ejaculatory ducts. This was a case 
in which chronic relapses of gonococcal urethritis were suppressed only 
by cauterization of the verumontanum. This had to be destroyed by 
the actual cautery, thus leaving the ejaculatory ducts exposed like two 
gun barrels lashed together. 




FiR. 1. 





Fig. 2. 



PLATE V 



Fig. 3. 



URETHROSCOPY OF XORAEAL AXD rATlfOLOGIC UUETIIRA 105 

ooniiciicci i'(jr sui-Ii u \ini'^ pcriml liail ;i|ijiarciitly l)C(>ii destroyed conijiletoly. As a coiifirma- 
tidii of tliis jit'ilcct cure of the patient, I siiw iiiiii ii{;aiii on July 25, IfllO. Havin<r gone for 
a fortnight without any treatment, he clechired witli great pleasure that there was no dis- 
charge and Ills urine was clear without the slightest trace of filaments or ^reds. 

"With tlic urclliroppopo I notifod that there no longer existed any evidence of a purulent 
cyst or a |iath(il(ii;ic focus iu tlic ]inst('rior urctlira liiat might act as a nidus for the gonococcus. 
The veruinonttinum still showed the presence of a sliglit chronic inflammati-on, this being 
made evident by a distinct edematous appearance. I cauterized the summit and painted the 
entire body of the verumontanum. lightly witii tincture of iodin. From that time on, the 
cure was complete and the gonococei never returned. 

Dc'svif^iies, of Limoges, lias imblislied' the following interesting re- 
port on this subject : 

''On Dec. 28, 1910, B., aged thirty-four years, presented himself for consultation to our 
chief, Luys, complaining of a morning drop. He had contracted gonorrhea a year previously 
and had been treated with irrigations of permanganate and oxycyanide of mercury. A series 
of local applications of silver nitrate had been made and large Beniquc sounds up to No. 60 
had been passed. 

' ' The urine presented large heavy shreds in the first glass and the fourth glass was 
clear. Microscopic examination of the morning drop revealed the presence of numerous leuco- 
cytes with a few diplococci wliicli did not resemble the gonococcus. The meatus was normal ; 
the foreskin free, no paraurethral fistula. Per rectum, the prostate and seminal vesicles were 
negative ; likewise the massaged ex2:iression of these glands ; Cowper 's glands also negative. 

.''Luys then decided to ajiply urethroscopy, using his instrument with tube Xo. 60. In 
tlie posterior urethra, he noted the following: At the upper part of the prostatic fossette, 
three large edematous and whitish projections indicative VDf a chronic prostatitis, constituting 
a hernia into the urethroscopic tube. The entire mucosa of the posterior urethra was uni- 
formly red. In the anterior urethra he noted a slight hardening of the bulbous region; a few 
Littre"s glands were situated on the .upper wall. 

' ' The anterior urethra was dilated with a straight Kollmann dilator up to Xo. 90 ; then 
dilatation of the posterior urethra with a curved Kollmann was alternated with massage of 
the prostate. 

"April 6: The patient had no morning drop but still showed some filaments in the 
first glass of urine. Urethroscoj)y : The minor lesions 'of the anterior urethra had dis- 
appeared, and the appearance of the posterior urethra had changed considerably. It was 
much less inflamed and in place of the large edematous circumscribed projections in the 
prostatic fossette three whitish vesicles which seemed purulent in character, were observed. 
These vesicles were cauterized. 

' ' Ten days later cauterization was repeated. The ijaticnt reported feeling much bet- 
ter and presented nothing but a few thin floating filaments in the first urine. All treatment 
was now suspended. The patient was seen again early iu June, 1911, and had no filaments 
whatever in the urine. 

"In conclusion, this rej^ort indicates clearly that through urethroscopy alone was a 
correct diagnosis and appropriate treatment made jjossible in this case, which had resisted 
all other tlierapeutic nu'thods at our command." 

The study of the prostatic fossette is extremely interesting in 
chronic prostatitis. It is Avell to rememher, in this connection, that the 
orifices of the infected follicles open on the lloor of the fossette. Look- 
ing at this region through the urethroscope Avhih^ the i3rostatic lobes 
are massaged with one finger in the rectum, streams of pus may be 
seen gushing forth from the infected glands. The glandular oritices 



106 CYSTOSCOPY AXD rEETHROSCOPY 

from ^vliicli jdus is most frequently evacuated are found on the lateral 
margins of the Termnontanum on a level with its base. 

In two cases of chronic prostatitis which were apiiarentl^^ abso- 
lutely incurable, I have been able to observe that pus exuded from sev- 
eral gland orifices on the side of the verumontanum Avhen pressure was 
exerted on the prostate through the rectum. In these two cases, I 
succeeded in greatly enlarging these orifices, which had caused reten- 
tion of the iDus because they were too narrow. 

In a man thirty-four years of age, the orifice was enlarged with a 
galvanocautery point and behind it we found a real "prostatic cavern" 
(Plate A% Fig. 1). This was subsequently easily disinfected with 
swabs of cotton steeped in silver nitrate or resorcin. In both cases I 
was specially struck with the enormous dimensions of these prostatic 
caverns. "With the original orifice so narrow, the great size of these 
caverns is not usually susiDected. It is, therefore, evident that these 
urethroscopic researches are of the greatest importance, for it is only 
by their aid that we are able to find the solution of the problem so often 
placed before us; namely, the cure of these old and seemingly incural)le 
cases of prostatitis. 

Localization of chronic urethritis in the posterior urethra is ex- 
tremely common, notwithstanding the general belief to the contrary. 
It is true that in an acute inflammation, it is im^DOSsible to make ure- 
throscopic observations because of the hyperemic condition of the 
mucosa; in the chronic stage, however, when the entire posterior ure- 
thra can be examined deliberately and carefully, the reason for the ex- 
istence of otherwise inexplicable s^^miptoms will usually be revealed. 

The posterior urethra is seriously altered in hard infiltration: the 
membranous region takes on a grayish red, slightly yello"v\dsh color, its 
brilliant luster disappears and gives place to a dry and dull appear- 
ance. The epithelium desquamates freely so that it may be denuded 
over a very considerable extent: it is this more or less complete des- 
quamation that is responsible for the bleeding which is so easily pro- 
duced by the introduction of the urethroscope. 

The mucous folds which are normally so numerous in the mem- 
branous region, disappear almost com^Dletely under the influence of fi- 
brous infiltration. "When this is very nmeli pronounced, it is no longer 
possible to see anything except a rigid tube of yellowish or jDcaii Avhite 
color. Wlien the latter tint predominates, it is an indication of the 
presence of pachydermia of the nmcosa. 

Vegetations and polypi are frequently situated either on the veru- 
montanum or in some portion of the posterior urethra. Xot infre- 
quently their existence coincides with neurasthenic j)henomena of an 



URETHROSCOPY OF XORMAL AXD PATHOLOGIC URETHRA 107 

extremely marked type. Sometimes they are on tlio verumontaiium it- 
self (Fig. 70). In this particular case, it appeared in the form of a 
cock's comh and it was not at all difficult to cause its disappearance 




Fig. 70. — Polypus on the summit of the verumontanum. 

with the galvanocautery point. In other cases, they take on tlie ap- 
pearance of long polypi resembling eels (Fig. 71). They may then 




Fig. 71. — Long eel-shaped polypus on the anterior aspect of the verumontanum. 

assume the most fantastic forms according to the way they are made to 
move in one direction or another under the influence of the i^resence of 
the urethroscope. [This is beautifully shown in the modern water- 



108 CYSTOSCOPY AND UKETHEOSCOPY 

dilating urethroscopes. The current of water striking the long, slender 
polypus, carries it along in the direction of the bladder, and when the 
flow of water is stopped, it returns to its normal iDosition. Intermit- 
tently making and breaking the flow of water gives an unusually strik- 
ing picture. — Editor.] The phallus-shaped polypus shown in Fig. 72, 
gives a good idea of the form they can assume. 

Occasionally they lie in the membranous region, or they are pedun- 
culated, with a long stem. Or they may take on a cauliflower appear- 
ance invading almost the entire posterior urethra and covering the 
veruniontanum completely. These cases are the most difficult to treat 
because of the extensive cauterization which they necessitate, at the 
same time taking precautions to preserve the ejaculatory ducts intact. 




Fig. 72. — lyOng phallus-shaped polyp on the superior aspect of the veruniontanum. 

I have had the .opportunity to observe a similar case in a young 
man of thirty-five, Avho presented frequent gonococcal relapses. The 
center of infection was in the posterior urethra which was completely 
invaded with raspberry-like vegetations. Notwithstanding systematic 
dilatations of the posterior urethra with Franck's dilator up to No. 45, 
relapses still continued to occur. Urethroscopic treatment Avas then 
applied. It consisted of applications of the actual cautery to the entire 
posterior urethra; these cauterizations could not be made without di- 
rectly attacking and destroying the veruniontanum, thus leaving the 
ejaculatory ducts exposed. This is well shown in Plate V, Fig. 3. The 
veruniontanum no longer exists and the ejaculatory ducts look like two 
gun barrels fastened to each other. 



URETHROSCOPY OF NORMAL AND PATHOLOGIC URETHRA 109 

The orifice of the prostatic utricle is often widely dilated and the 
seminal fhiid may be seen exuding from its lumen. In certain cases 
when it is necessary to estal)lish the differential diagnosis between 
prostatic and vesicular secretion, urethroscoi3y may l)e conil)ined witli 
massage of the prostate, to great advantage. By this means, seminal 
fluid can be made to exude from the prostatic utricle and the pros- 
tatic ducts under the observer's eye; in this way, extremely useful data 
may be revealed wdiich will often indicate the most suitable and effec- 
tive therapy. 

Occasionally the prostatic utricle is shifted to one side or another 
of the verumontanum instead of occupying the median line; and in 
cases of chronic ex)ididymitis it is not unusual to observe a purulent 
secretion emanating from the prostatic utricle. Again, the lips of the 
utricle may be congested and verrucous, and will bleed at the slightest 
irritation; this condition explains one of the symptoms of which pa- 
tients with chronic posterior urethritis often complain; namely, blood- 
stained seminal ejaculations. 

When the verumontanum has been invaded by fibrous tissue, it 
becomes yellowish in color and appears as if it were dried up and rum- 
pled. In these cases, the orifice of the prostatic utricle and the ejacu- 
latory ducts may be contracted or entirely choked up. These lesions 
account for the sharp pain at the moment of ejaculation, wliich is so 
pathognomonic of certain cases of cJironic prostatitis. In other in- 
stances, we encounter simple hypertrophy of the verumontanum, wdiich 
is usually associated with the habit of masturbation. For a view of 
the "masturbator's verumontanum" see Fig. 73. This j)icture is so 
true that I have very often been able to accuse certain jDatients of mas- 
turbation wdio confessed the practice of this habit only when confronted 
with the existing lesion. In these cases there is a considerable hyper- 
trophy of the verumontanum which gives it an appearance resembling 
the uterine neck involved in metritis. The utricle becomes wide and 
gaping, and takes on the aspect of the mouth of a tench. The veru- 
montanum and the ejaculatory ducts may undergo otlier and more 
varied changes; these are studied in detail further on (see Catheter- 
ization of the Ejaculatory Ducts, page 115). 

Posterior urethroscopy is also extremely useful and interesting in 
prostatic hypertrophy. In this condition, most exact information can 
be derived concerning the length of the prostatic tunnel, of the shape 
of its walls and of all its sinuosities ; also of all the abnormal protuber- 
ances that may be encountered; the latter being responsible for the 
urinary difficulties that the patient complains of. 

It can also be seen how it is possible to destroy these projections. 



110 CYSTOSCOPY AND URETHROSCOPY 

which prevent normal micturition, under control of the eye. Its thera- 
peutic value in these conditions can also be appreciated. Let it be un- 
derstood, of course, that one can not dream of supplanting tralrisvesical 
prostatectomy in this manner; but it is nevertheless true that this 
method can be of distinct service in many cases. Undoubtedly it is far 




Fig. 73. — Hypertrophied verumontanum, the result of a chronic inflammation. The organ resembles the 
uterine neck. (Masturbator's verumontanum.) 

superior to the blind section emj^loyed in the Bottini method, since it 
permits the cauterization of the exuberant portions of the prostate to 
be done directly under the control of the eye (see Urethroscopic Treat- 
ment of Prostatic Hypertroi^hy, page 135). 

EEPERENCES 

iWolbarst : Colliculitis, or Disease of the Verumontanum, Med. Rec, New York, Oct. 4, 1913 ; 

The Oollieulus Considered as a Factor in Chronic Disease of the Male Urethra, Am. 

Jour. Surg., October, 1914; Ann. Surg., October, 1915, p. 477. 
sDesvignes: De la neeessite de I'uretroscopie dans le diagnostic de I'uretrite posterieure 

chronique, La Clinique, 1911. 

Urethroscopy in the Female 

Urethroscopy in the female is just as necessary as it is in the male. 
It goes without saying that this examination shall not be made in 
either sex without the urethra having been sufficiently dilated pre- 
viously. In the female, a short urethroscopic tube should be used; this 
has already been described (see page 43). 

However, as there are numerous instances in Avhich the vesical 



URETHROSCOPY OF NORMAL AND PATHOLOGIC URETHRA 



111 



iiock in tlio femaiG also particiiDates in clii-oiiic iiiflanniiation of tlio 
nretlira, it is often advisable to examine tlie l)la<l<ler neck and the 
deei^er portion of the urethra at the same time. But when the simple 
iiretlu'oscopic tube enters the bladder the fjresenee of tlie urine prevents 
a clear view of the lesions existing at the vesical neck; consequently 
a special instrument is necessary and I recommend for this purpose 
the female model of my direct vision cystoscopy 

Whether we employ the simple tube or the direct vision cysto- 
scope, the entire urethra must be examined from the neck of the bladder 
to the urinary meatus. During the passage of the instrument from 
behind forward, toward the meatus, it will be possible to study care- 
fully all the peculiarities of the mucosa, — the little polypi, the papil- 
lomata, and the orifices of the urethral glands. 




Fig. 74. — IvUys' direct vision cystoscopc, female model, complete. 



The vesical neck of the female deserves quite special attention. 
It should be examined with the direct vision cystoscope, both on its 
vesical side as well as on its urethral aspect. Important lesions may 
thus be found of which we might otherwise remain in complete 
ignorance, and the disorders which they give rise to would continue 
indefinitely with their causes undiscovered. 

At times, Ave find well-developed polyi^i, such as are shown in 
Plate XVII. In this particular case, the patient was referred to me 
with the diagnosis of bladder tumor. Though her urine contained 
l)lood, cystoscopy demonstrated positively that she had no tumor in 
tlie bladder. However, she did have several small polypi at the vesical 
neck, which clearly explained the bloody urine. 



112 



CYSTOSCOPY AXD UEETHEOSCOPY 



These polypi may exist only in rude outline. In Plate XX., Fig. 1, 
the cervical mucosa can be seen extremely congested with projecting 
areas of congestive edema, which seemed as if it Avould eventuftlly end 
in the production of iDolypi. 

Occasionally real abscesses, not very large, can also be seen at 
the vesical neck; these abscesses may be the cause of the repeated 
urethral reinfections so often encountered. In Plate XX., Fig. 2, a 
rather large abscess can be observed situated on the urethral aspect 




Fig. 75. — Large pediculated polypvis in tlie female urethra, implanted on the floor of the urethra. 

of the vesical neck. The young woman who had this lesion suffered 
from continued relaiDsing attacks of urethritis which could not be 
explained by the appearance of the anterior part of her urethra. This 
abscess, which had resisted urethral dilatation, was opened by means 
of the galvanocautery. The cautery point first ruiDtured the abscess 
wall; this brought forth a flow of pus and then completely destroyed 
the entire purulent pocket and resulted in a complete cure of the patient. 
In the female urethra, two cpiite distinct anatomic parts should be 



TTlETTTPXiSforV or XOr.A.IAL AX' I r.\T ]]()]. nciC rRETTTRA 113 

(listiiiuiiisliod: P'ii'>t. llic ])osici'i()i' jxiiiioii wliicli adjoin.'? the neck of 
IIm' l)la(l(ler and is entirely niuseular in structure. In this: portion 
uretliroscop}' slioAvs the presence of abundant muscle fibers which are 
indicated hy the presence of regular, well-marked radiations. This 
])ait of l]i(' uiollna is less frequently attacked l)y inflammatory proc- 
esses, lor it is almost devoid of glands. Secondly, the anterior portion 
of the urethra is very diiferent from the posterior portion be- 
cause of the abundance of glandular orifices. These glands are 
constant and constitute two important lateral groups. Anatomically, 
they are mucous glands and they open on the surface of the urethra 
l)y means of rather well-developed orifices, which can be seen plainly 
with the urethroscope. These glandular orifices strongly simulate the 
glands in the male penile urethra in appearance and structure, being- 
homologous with the glands of Littre and the lacunae of Morgagni. 
Like the latter they are liable to gonorrheal inflammation with all its 
consequences. The existence of these glands is probably responsible 
for the tendency of the gonococcal infection to joersist in the female 
urethra; they may also account for the frequent development of polypi 
at the external orifice of the urethra (Fig. 75). 

The logical conclusion to be drawn from these data is that the 
]nost satisfactory treatment of chronic gonorrheal urethritis in the 
female is identically the same as that in the male; namely, dilatation. 

The necessity of urethroscopy in the female forces itself upon ns, 
for this method of examination alone i^ermits us to make the most 
surprising diagnoses, which would otherwise be absolutely impossible. 

The following report will illustrate this more fully: 

A woman, forty-four years of age, was referred to me on June o, 1905, by Terrier. 
She said she had been operated upon five years previously, for a tumor of the bladder; the 
urine was clear and there was no increased frequency, but she suffered intense pain during 
and after the act of urination. 

In the belief that the vesical tumor had recurred, the patient had several times visited 
Albarran, who had operated on her, but he declared, after examination, that he found no 
lesion whatever in the bladder. Then she consulted Terrier, who sent her to me. 

Clinically the bladder showed nothing abnormal ; its capacity was over 300 c.c. The 
vesical wall was entirely normal and painless to the touch. Further examination with the 
prismatic (indirect) cystoscope proved tliat the organ was alisolutely normal and that there 
was no recurrence of the tumor. 

On June 2?, I made another examination witli my direct vision cystoscope, and I again 
noted that the bladder appeared normal. I was preparing to suspend the examination and 
was slowly withdrawing the instrument which was still in the urethral canal, when the lumen 
of the tube was suddenly and completely inundated with a muddy liquid Avliich was ap- 
parently purulent. After this fluid was evacuated and the mucosa dried, I inspected the 
urethral wall. I found that there was an orifice on the right lateral wall, about two centi- 
meters from the meatus, which led into a paraurethral cavity. Pressure exerted by the cysto- 
scopic tube on this cavity, brought forth a muddy liquid accomiianied by purulent clots. In 



114 CYSTOSCOPY AE-D URETHROSCOPY 

this case, we were undoubtedly dealing with a paraurethral abscess, which had been rup- 
tured by the pressure of the cystoscopic tube. 

Subsequently the bottom of the cavity was cauterized with a fine silver nitrate pencil 
and the paraurethral orifice enlarged with a thin galvanocautery point so as to provide better 
drainage. Under the influence of this treatment, the patient's pains ceased and disappeared 
entirely. 

The following is another illustration of the great importance of 
urethroscojoy in the diagnosis of nrethroc^^stic affections in the female : 

A woman was referred to me in October, 1910, complaining of severe pain in the blad- 
der and urethra both during and after micturition, for a period of seven months. The pre- 
liminary examinations were rendered very difficult owing to the extreme sensitiveness of the 
urethral canal; but with a little patience, systematic dilatation of the canal was accomplished, 
so that the urethra was sufficiently dilated by the end of November to enable me to introduce 
my direct vision cystoscope. 

On November 22, I found that the entire bladder was perfectly normal; likewise the 
posterior portion of the urethra. But in withdrawing the tube slowly I noticed a little 
edematous orifice on the left lateral wall through which some drops of pus were exuding. 
Catheterization of this orifice with a fine wire was j)ractically imjiossible. The lesion was 
undoubtedly a paraurethral fistula. 

Later on, this orifice was enlarged by the galvanocautery, thus facilitating evacuation 
of the pus. A few days after this treatment, the patient passed large masses of purulent 
clots, which, on analysis by Hallion, consisted of pus, and numerous ill-defined bacterial 
forms ; the gonococcus and Koch 's bacillus were not found. 



CHAPTER III 
PRACTICAL APPLICATIONS OF URETHROSCOPY 

ITretliroscopy is not liiiiitod in its usefulness to the examination of 
the urethral mucosa. Its field of application has become greatly ex- 
tended so that it is today considered of the greatest value in the diag- 
nosis of conditions involving the urethra and its adnexa, especially 
tlie prostate, seminal vesicles, and Littre's glands; it has likewise 
proved its great value in a surprisingly efficacious manner in the therapy 
of these organs, particularly of the seminal vesicles and the prostate. 

We shall, therefore, take up in succession, first, catheterization of 
the ejaculatory ducts, and second, the endourethral treatment of pros- 
tatic hyx^ertrojDln^ 

CATHETERIZATION OF THE EJACULATORY DUCTS 

When we consider the astonishing facility Avith which we catheter- 
ize the ureters today, thanks to the perfection in modern technic, it 
is surprising indeed that Ave have not made similar advances in the 
catheterization of the ejaculatory ducts; yet notwithstanding this 
failure, medical literature is practically silent on this subject. 

In 1905 Klotz^ made several attempts to catheterize the ducts. 
He devised a little special syringe provided Avith a fine cannula Avliich 
he introduced into the orifice of the ducts hoping thereby to inject 
solutions into the seminal vesicles, but the results Avere not satisfactory, 
inasmuch as his injection Avas folloAved by epididymitis. This attempt 
of Klotz, hoAvcA^er, marked a neAv era in this Avork; for it gaA^e the 
first promise of a means of- access toAvard the dark and mysterious 
sinuosities of the seminal vesicles. Undoubtedly the solution of this 
subject Avill be found in the further perfection of the technic of ure- 
throscopy. 

Belfield- also succeeded in catheterizing the ducts. But Avhen he 
found the search for these orifices rather difficult especially in patho- 
logic cases, he resorted to rather complicated expedients in order to 
make the orifices of the ejaculatory ducts more easily discernible. By 
means of a puncture in the A^as deferens near the groin, he injected 
some milk Avith Avhich he filled the corresponding seminal vesicle. 
Subsequently, by making pressure on the milk-filled A'esicle through 

115 



116 



CYSTOSCOPY AND I^RETHEOSCOPY 



tlie rectum, lie was able to obtain a better view of tlie ejaculatory 
orifices and tlms succeedetl in catlieterizing them. This method was 
not only complicated, but also not without its dangers. ^ 

However, it may be stated that catheterization of the ducts is not 
only possible, but absolutely demanded in certain cases. 

Anatomic Considerations 

If researches on the cadaver are to be taken as our guide in 
the study of catheterization of the ducts, we are apt to be disappointed 
in the results olitained. In the cadaver, the verumontanum and the 
ejaculatory canals are certainly much more difficult to locate than in 
the living subject. This is due to the fact that the verumontanum 



|v.- --^^f-'. 




Ik 







Fig. 76. — Classic arrangement of the ejaculatory canals, situated symmetrically on either side of the 

verumontanum. 



being essentially an erectile organ, is normally very vascular and filled 
with blood, and in the cadaver is much reduced in size; consecjuently 
the duct orifices are much more difficult to find. This difficulty of 
catheterization in the cadaver is true of all body canals, and particu- 
larly so as regards the ejaculatory ducts. 

The best way to recognize the ejaculatory ducts is to inject a little 
water into the lumen of the vas deferens; then on massage of the 
vesicle, the urethroscope in situ, we can see the fluid entering the 
urethral canal in the form of a fine jet, and this enables us to identify 
the corresjDonding duct and thereby note its exact position. 

In cooperation with Pelletier, we instituted a series of urethro- 
scopic experiments on the cadaver and on a living subject, to determine 



CATHETEIMZATIOX OF E.IACULATOKY DUCTS 



117 



tlic ari';iii,i;ciii('iil of the ("jaciihilory (liicls in i-elalioii to the i)roslatie 
utricle ami llic Ncniiiioiiiaiiiiiii. 'I'lic conclusions Ave arrived at differ 
considerably from the usual anatomic conception. In ])oint of fact, 
autliors usually dcscrihc tlie oi-ilices as Ixun.ii,- situated most frequently 




Fig. n . — \'erumontanum wilhout any visible orifice. 



on tlie sides of the yerumontanum and symmetrical with the utricle. 
The Yerumontanum is then found to contain three openings: The 
prostatic utricle in the median line, and the ejaculatory orifices on 
either side (Fig. 76). 





Fig. 78. — Ejaculatory canals opening on the lips of the prostatic utricle. 

Tliis clinical descrii)tion is far rroiii correct in the vast majority 
of cases. In eleven cadavers which we studied, this arrangement was 
met with only three times. In fact there are cases, rare it is true, in 



118 



CYSTOSCOPY AND URETHROSCOPY 



wMcli it is not possible to see any orifices at all, neither the prostatic 
utricle nor the duct orifices being visible. But these instances are 
almost always pathologic in character. '*' 




Fig. 79. — No prostatic utricle visible; the ejaculatory CEiials open on the lateral walls of the verumontanmn, 

resembling a diver's helmet. 

A second disposition of the orifices which is quite frequent, is that 
in which a median utricle is seen, and on its lips or edges are the orifices 
of the ducts (Fig. 78). This arrangement was noted seven times in 




Fig. SO. — The ejaculatory canals open on the lateral walls of the verumontanum but at different levels. 



our study of the cadaver. Still another arrangement is that in which 
there exists no median utricle, but the ejaculatory ducts open on the 



CATHETEIIIZATION' OF E.I ACl'I ,AT011Y DUCTS 



119 



lateral walls of the veniinontaiiiuii (Fig. 79). This is the "diver's 
helmet" appearance, which I have already described.'^ In this type, 
the duct orifices are usually placed symmetrically on cither side of 
the median lin^there are instances, however, in which they are not 
on the same horizontal plane, hut one lower than the other (Pig. 80). 




Fig. 81. — Urethroscopic view in which the prostatic utricle is visible; the ejaculatory canals can not be seen. 

The ejaculatory ducts may be altogether invisible in another type. 
The median utricle can be seen, however, and it is only wdien an inci- 
sion is made above and below it, that the ducts Avill be found at the 





Fig. 82. — The ejaculatory canals were made visible only aflcr incision of the utricle; they were found 

at the base of the utricle. 



bottom of the utricle, lying close to one another like two gun l)arrels 
(Fig. 82). This arrangement was encountered but once in the eleven 
cadavers studied. 

Lastly, there is the type, very rare indeed, in which the verumon- 



120 CYSTOSCOPY AND URETHROSCOPY 

taimm is destroyed tlirongli cauterization witii silver nitrate or the 
galvanocautery. Tlie walls of the organ disappear and helow them 
nothing remains but the two ejaculatory canals, fastened togetlTer like 
gun barrels (Fig. 83). This occurs in cases in which the destruction 
of the verumontanum has been made necessary by the persistence of 
the gonococcus in the walls of the verumontanum. 

In conclusion, we ma}^ say there are two princii3al types: In the 
most common type, the ejaculatory ducts open upon the lips of the 
utricle; the other is the classic type above referred to; namely, the 
median utricle and lateral orifices. All other types are anomalies, 
but it should be borne in mind that they are quite common, nevertheless. 

It is interesting to note that a catheter introduced into the ejacu- 




Fig. 83.— Gun-barrel aspect of the ejaculatory canals. 

latory ducts will alwa^^s pass into the seminal vesicle and never into 
the vas deferens. This observation is confirmed l3y our studies on the 
cadaver, and is of considerable importance since it is a useful aid in 
securing direct drainage of the seminal vesicles. It is, therefore, quite 
probable that the successful catheterization of the ejaculatory ducts 
will bring with it an effective means of drainage of the seminal vesicles. 

REFEREl<rCES 

iKlotz: New York Med. Jour., Jau. 26, 1895. 

sBelfield: Catheterization of the Ejaculatory Ducts, Section on Genitouriuaiy Diseases, Jour. 

Am. Med. Assn., 1912, p. 24. 
sLuys: La Clinique, Feb. 14, 1913, No. 7, p. 98. 



CATHETERIZATION OF E.7 AGQLATOIIY DUCTS 121 

Indications for Catheterization of the Ejaculatory Ducts 

Catheterization of the ejaculatory ducts is demanded ivhenever 
there are disturbances in the function of seminal ejactdation and gen- 
erally speaking, in all cases of chronic spermatocy stitis . 

In point of fact, catheterization ought to be an indispensable fea- 
ture in tlie treatment of spermatocystitis. In this condition the infected 
seminal vesicles have to be treated in the most thorough manner from 
one end to the other; that is to say, by massage of the body of tlie ves- 
icle as well as by dilatation of its excretory duct. Dilatation is the in- 
dispensable complement of the massage, which empties and expresses 
the vesicular contents, while the dilatation facilitates and insures this 
desired effect. 

It is well to remember the frequency of chronic spermatocystitis 
in gonorrhea, and on the other hand, the ease A\dth Avhich this pathologic 
condition remains latent for a very long period. These lesions are not 
only unknown to the patient, w^ho feels no pain in or near the infected 
parts, but also to the physician Avhose attention is not sufficiently at- 
tracted to its possible existence. It is indeed extraordinary, that well- 
informed physicians who are familiar with the genitourinary organs 
so often examine the prostate but utterly neglect the seminal vesicles 
which are far more important. 

The predominating factor favoring the localization of cbronic in- 
fection in the seminal vesicles is the complete absence of all spontaneous 
pain and the paucity of symptoms. This focus of infection must be 
investigated thoroughly again and again; and in all cases of urethritis 
which exhibit a tendency to last too long, the best way to recognize this 
focus is by digital contact through the rectum. But this is so often 
rendered difficult by reason of the inaccessible situation of the vesicles 
and the stoutness of the patient, that it is necessary to place the patient 
in special positions in order to examine the seminal vesicles properly. 
These little organs are encountered by the examining finger in the 
rectum when it has passed above and l)eyond the lateral lobes of th(^ 
prostate. But an inexperienced observer may very readily pass by a 
diseased vesicle without recognizing it. 

There are four principal diagnostic signs l3y which we may knoAv 
whether the seminal vesicle is diseased or healthy, as follows : 

1. Pain. An infected seminal vesicle is always painful or tender 
to the touch ; this sensation of pain must be compared with the opposite 
side to bring it out more fully. Sometimes it is severe enougli to cause 
syncope, and it may develop an immediate lypotliymia. 

2. Induration of the walls of the seminal vesicle. 



PLATE VI 

Fig. 1. — Prostatic cavern ol)served in cJironic prostatitis. To the left of 
the picture the left maigiu of the verumontanuin Avill be noted. Ad- 
jacent to the verumontanum is the comparatively large mouth of the 
prostatic cavern. Some urine always accumulated in this pocket. This 
cavern always gave forth a purulent, urethral discharge. It was only 
through a widening of the mouth made by the galvanocautery and a 
complete cleansing with tincture of iodin that the cavity was disin- 
fected. 

Fig. 2. — Uretliroscopic vieio_ of a urethral stricture. The mucosa has 
a cardboard-like appearance. The urethral walls are invaded by fibrous 
tissue; they have no elasticity and can not approximate each other at 
the central lumen. They resemble a funnel of rather pronounced type. 
Littre's glands, chronically inflamed, are seen in profile on the fibrous 
urethral walls ; one can also notice the bleeding clefts or cracks on 
the wall which are the results of dilatation, this having the same 
effect on the fibrous mucosa as so many little internal urethrotomies. 




Fig. 1. 




Fig. 2. 

PLATE VI 



CATIIETElll/ATlOX OK E.JACULATOUY DL'CTS 



123 



3. Vesicular expression brjjigs J'oi-ili i-allicr large, i-ihhoii sliapcMl 
vesicular casts (Fig. 85). 

4. Sensitiveness or pain in tlio r(\<;ioii of tlic verumontaimm, which 
is determined by the aid of tlie olivary bougie. Wlion tliis pain is 




Fig. 84. — A stylet introduced into the orifice of the ejaculatory canals, enters the seminal vesicles, and 

not the vas deferens. 

encountered, it is the indication of a chronic painful infianimation of 
the verumontanum and not of a peculiar nervous or neurasthenic con- 
dition as was formerly too often believed to be the case. This little 




Fig. S5. — "X'esicular casts," obtained by massage of the seminal vesicles (drawn from nature). 

organ, Avhich is situated at the mouth of the ejaculatory ducts, under- 
goes inllammation by the very reason of its location, and its pathologic 
involvement is almost always in direct relationship with the coexisting 



124 CYSTOSCOPY AjSTD ueetheoscopy 

inflammation of the seminal vesicles. Tliis tenderness to tlie toueli 
might very properly be termed the "nrethrovesicnlar reflex." 

Apart from these distinct symptoms which make the di?rgnosis 
fairly certain, there is a series of symptoms which mnst also attract 
attention. These are the folloAving: 

1. The nrine may be turbid or clear, with shreds in the first glass, 
or phosphatic. 

2. Urinary disorders, such as dysuria or iJoUakiuria; both of wliicli 
may sometimes be confused with cystitis. 

3. Spontaneous pains but always indefinite and vague, referred 
to the perinemn, testicles, kichieys, or tliighs. 

4. Eeflex pains far removed from the seat of the lesion, stick as 
sciatic neuralgias, or renal pseudocolic. 

5. Genital disturbances characterized by painful ejaculation, or 
symptoms of sexual weakness or nnpotence, or finally, by an abnormal 
yellowish or bloody discoloration of the seminal fluid. 

6. Eecurrent epididymitis. 

7. Most important of all, indefinite disturbances, consisting of 
general asthenia and complete body fatigue. This condition of fatigue 
disappears quickly under the influence of treatment for spermato- 
cystitis and patients soon recover their general health, strength, and 
energy; the body weight is also improved measurably. 

These patients suffer for many years from a sensation of heaviness 
in the hypogastrium, dull pains in the perineum, in the Imnbar region 
or the thighs, as well as from scalding on urination: they also c-oniplain 
of a considerable decrease in sexual virility as well as ejaculatory dis- 
turbances. They have a slight urethral oozing every morning and 
shreds in the first glass of uritie. Usuall^^ they have consulted a con- 
siderable number of physicians, surgeons, and specialists, and tlie result 
of these consultations has always been the same. "You are a neuras- 
thenic — a nervous person," they say to the patient, adding that there 
is nothing the matter with him and advise him to pay no further 
attention to his troubles, and that they ^-ill disappear of their o^mi 
accord in due course of time. 

The result of these persistent disorders is that tlie unfortunate 
patient is soon brought under the influence of a j^ermanent and irre- 
pressible obsession with the fixed idea that he is incurable, that lie 
a\t11 never be well again, that he may never marry, and that his life 
is ruined forever. 

These chronic lesions terminate in a pitiable neurasthenic condition 
which keeps the victim always preoccupied making life impossilDle and 
sometimes ending with suicide. It has been my fate to have been pres- 



CATHETEniZATroX OF E.) ACrLATOltV DUCTS 125 

('lit twice ill the role of a ]it'l])lc»ss spectator at a catastro])li(' of tliis 
kind. 11 is a])S()1u1('l\- necessary that the medical profession should 
liave its attention aroused on these matters. Unfortunately, too often 
the unhappy patient presenting these symptoms is treated as nerv- 
ous and iKMirastlK'iiic, wlicreas it wonhl he a really simple mattei- 
to make a methodical examination of the posterior urethra, discover 
the lesions and give them ajjpropriate treatment. 

S. Jorge de (Jouvea, of Rio de Janeiro lias reported^ the following 
interesting case of sexual neurasthenia cured by endoscoiw: 

''Sexual neurasthenia in the male often has its starting point in a pathologic condi- 
tion of the posterior urethra. These elironic lesions, almost all of gonorrheal origin, are 
usually localized in the verumontanum which we know enjoys an abundant nerve supply. We 
can therefore readily understand how it happens that a pathologic process which gradually 
brings about such exten.<;ive anatomic changes, is able to produce so many local neiTOus 
disturbances which react on tlie general condition of the patient. 

""Whenever in a neurasthenic, disturbances pointing to the urogenital system become 
manifest, it is absolutely necessary to have recourse to the modern methods of examina- 
tion of the urinary apparatus. Endoscopy enables us to determine exactly the seat of the 
lesion which is giving rise to these general disturbances; likewise we are enabled to treat 
the lesion in a rational manner under control of the eye, thus bringing about a cure, not 
only of the local lesion, but also an amelioration and even a complete cure of the constitu- 
tional disturbances. 

' ' This is what I have been able to report in the following case in which the Luys ' 
urethroscope enabled me to determine the cure of a series of disorders which caused my 
patient to lead a life that was liractically unbearable. As soon as the diagTiosis was made, 
a complete cure was readily obtained, as will be seen from the following history: 

"M. F., a soldier, forty years of age, consulted me on July 20, 1910. He had his first 
gonorrhea eight years previously and had treated Mmself with, injections of nitrate of silver 
and sulphate of zinc. He was left with a morning drop which almost disappeared when 
he irrigated the urethra with j)ermanganate, but which became aggravated whenever he com- 
mitted an excess of any kind. 

' ' At the time of the examination, he is forced to urinate frequently, small quantities 
being passed each time. During the act he experiences discomfort and a sensation of heat 
which extends through the urethra and the perineum. At the end of urination he has violent 
erections. Xoeturnal pollutions are rather frequent and the emissions in coitus are pre- 
mature and painful. He has lost weight recently, is very nervous, hypochondriac and dis- 
couraged; digestion is poor, and he always has vague lumbar pains. The urine is clear with 
filaments in the three glasses. 

""With the bladder filled with a solution of oxycyanide of mercury, I examined his ure- 
thra. At the base of the penile region, I found a sensitive stricture made evident by a No. 12 
olivary bougie. The posterior urethra was also distinctly tender. The kidneys ajjparently 
negative, chronic prostatitis, painful seminal vesicles, Cowper's glands negative. 

' ' For fifteen days I irrigated him urothro-vesically, with permanganate and oxycyanide 
solutions. This was followed by internal urethrotomy witli Kollmann's urethrotome; no 
retention sound. At the end of four days I began progressive dilatation of the anterior 
urethra with straight metallic sounds up to Xo. 50. When I tried a Xo. 51, it passed easily, 
but on reaching the posterior urethra, it produced a sharp pain and gave rise to slight bleed- 
ing. Some days later I continued the dilatation after local anesthesia with novocaine and 
adrenalin. The dilatation was slowly increased until Xo. 55 was reached, and then I intro- 
duced a Luys' urethroscopic tube Xo. 55. 

"Examination of the posterior urethra sho\\ed that the cause of his illness lay in the 



126 CYSTOSCOPY AjSTD UEETHROSCOPY 

Terumontanum, which was swollen and covered with many small raspberry-like growths on 
its surface; its base was free. With a fine galvanocautery point, I destroj'ed these vegeta- 
tions and cauterized the surface with tincture of iodiii ; the operation was repeated a 
week later. During the succeeding month, I instituted a series of prostatic masSSges and 
deep instillations of silver nitrate, and the patient began to show signs of distinct improve- 
ment. I continued the massage and the endoscopy, cauterizing the verumontanum with iodin 
at each sitting. 

''At the end of three mouths the patient urinated freely, and did not complain any 
longer of the sensations which he formerly experienced. The improvement was fully con- 
firmed with the urethroscope. He no longer had his morning drop, his urine was normal and 
he passed it with normal freciuency. I saw him again six months later and his general con- 
dition was excellent. Undoubtedly the cure was permanent. ' ' 

REFEEENCE 
iDeGouvea: La Clinique, July 19, 1912, No. 29, p. 459. 



Treatment of Spermatocystitis 

The oj)erative treatment of si3ermatoc3^stitis has been studied 
chiefly by the Americans. The operations that have been proxjosed 
are the following: 

1. Vesiculotomy (Drainage of the Vesicle) proposed by Fuller, 
of New York. The patient is jolaced in the gennpectoral position and a 
curved incision is made in front of the rectum. To avoid injuring the 
latter, Fuller introduces the index finger of the left hand in the rectum, 
then with the index finger of the right hand introduced into the Avound 
made by a somewhat careful dissection, he searches for the space 
situated between the rectum, prostate and seminal vesicles. The 
vesicle having been located with the finger, he plunges a grooved 
director into it and on this he introduces a bistoury. [The vesicle is 
then drained for several days with a rubber tube. — Editor.] This 
operation is evidently done blindly and does not conform to the stand- 
ards of contemporaneous surgery. 

2. Vesiculectomy (Excision of the Vesicle), which may be done 
either by the inguinal, perineal, or the ischiorectal routes. This opera- 
tion is very difficult and involves considerable mutilation and risk. It 
is undoubtedly unsuitable in the vast majority of cases. 

3. Vasotomy (Vasopuncture), proposed by Belfield, of Chicago. 
He exposes the vas deferens near the inguinal canal, then introduces a 
fine silver cannula into the vas, through which he injects a solution 
of either argyrol, j)rotargol, or coUargol. In this way he maintains 
that he succeeds in flooding the seminal vesicle with the solution; he 
injects daily for several days, then removes the cannula and closes the 
incision. 

These surgical procedures seem, in most cases, altogether out of 



CATHETEPtTZATFON OF EJACULATOin' DUCTS ] 27 

proportion lo llic rolaiivc mildiioss of llio disease, so iiiufli so llial lliey 
should iiol l)e resorted to except in tlie most sei-ious and desperate 
eases. Tu llie vast majority of cases, tlie treatment of spermato- 
cystitis slionld consist of tlie folloAvinft': Massai^-e of tlie seminal vesi- 
cles, local li'caiiiKMit of ilic ^■('^ulll()ll1alllllll and calliclcri/.alion of tlic 
])rostatic utricle and of the ejaculatory ducts. 

Massage of the seminal vesicles is difficult and takes time, and 
must be repeated frequently for a long- period of time. It should 
l)e rememl)ered, in this connection, that many physicians do not usually 
succeed in massaging; the vesicles jiroperly, hut limit themselves to 
the prostate or the lower extremity of the vesicle.^ To massage or 
strip the vesicle properly the top of the vesicular ciil-de-sac must he 
reached and stripped Avith the finger from above dov\'nward. Unless 
this is done, massage of the vesicle is practically useless. 

On the other hand, though this treatment is highly effecti\'e when 
properly done, so far as the affected vesicle is concerned, it is insuf- 
iicient, inasmuch as it is absolutely essential to treat the other ex- 
tremity of the vesicle also, that is, the ejaculatory duct adjacent to 
the verumontanum. 

Local treatment of the vermontanum should be carried on under 
the control of the eye with the aid of the urethroscope. Unfor- 
tunately at the present time this is c{uite generall}^ ignored. The af- 
fected verumontanum is treated at frequent intervals. Above all, it 
is necessary to begin by diminishing the inflammation of the veru- 
montanum by means of copious urethrovesical irrigations and dilata- 
tion of the posterior urethra by means of curved sounds. And when 
dilatation has been carried far enough, so that a fairly large ure- 
throscopic tube can be introduced without undue difficulty, local treat- 
ment of the verumontanum should be begun. It should consist pri- 
marily in caustic aiDi^lications to the surface of the verumontanum. 

These direct applications are not usually painful and never pro- 
duce that tenesmus which is so disagreeable in the case of strong injec- 
tions; whereas on the other hand, they produce the most desirable and 
happy results. Under their influence the verumontanum rids itself of 
all the pathologic products which disfigure if, such as polyposis, edema, 
and ecchymoses. At the end of a certain period of treatment, the result 
is a perfectly smooth and regular verimiontanum with its princi]ial 
characteristics clearly defined and outlined. 

When this stage in the improvement has been aitained, it is de- 
sirable to explore carefully the prostatic utricle and the ejaculatory 
canals. Catheterization of these canals is necessary in the majority of 
instances, absolutely indispensable in many. The need of catheteriza- 



].28 CYSTOSCOPY Als^D URETHROSCOPY 

tion is due to tlie fact that these ducts very often undergo the same 
pathologic changes as tlie urethra in general, and there is no reason 
why the duct walls should escape the same fibrous alterations that take 
j)lace in the rest of the urethral canal. 

Since strictures of the urethra, which are tlie result of gonorrhea, 
are more or less frequent, strictures of the ejaculatory ducts must like- 
wise be frequent; and these strictures must necessarily exert consider- 
able influence on the pei'i^etuation of chronic spermatocystitis. In point 
of fact, because of the inflammation of its walls, the seminal vesicle is 
filled with pathologic products which appear in the form of "casts." 
Now, these vesicular casts have a certain volume which makes it impos- 
sible for them to pass through an ejaculatory duct, the lumen of Avhich 
has been narrowed by a stricture. 

Thus the evacuation of these gross jiathologic products can not 
take place during the seminal ejaculation. This exj^lains the fact ob- 
served in many instances, that during or after massage of the affected 
vesicle a sharp pain is often experienced, even perhaps an acute or- 
chitis; in these cases, there is no evacuation of the i^athologic products 
as the result of the massage. It is in these conditions that catheteriza- 
tion of the ejaculatory ducts is necessary and even indisiDensable.- 

REFERE]SrCES 

iFor full details, see Luys' Traite de Blenorragie, Paris, O. Doin, ed. 2, p. 308. 

-Le Catlieterisme des Canaux ejaculateurs. La Clinique, Feb. 14, 1913, No. 7, p. 98. 

Contraindications and Accidents Incident to Catheterization 
of the Ejaculatory Ducts 

The existence of an acute inflammation of the urethra or of the 
seminal vesicles constitutes the most general contraindication to 
catheterization of these ducts. The urethra must first be completely 
cleared up before the treatment of the ejaculatory canals can be con- 
sidered. Moreover, there should be no active inflammatory condition 
either in the seminal vesicles or in the posterior urethra. If these 
rules are adhered to, all accidents will be avoided. 

In some sixty odd cases in which I have catheterized the ducts, I 
have never had a single accident which could be attributed to this sur- 
gical procedure, and it is only because I have always acted with great 
circumspection, proceeding to the catheterization of the canals only 
after having thoroughly prepared and studied the individual cases. 



CATiiKTKin/A'rio.v Ml' ivi Aci ' 1 ,.\'i'( )i: ^• ducts \2U 

Injection Into the Seminal Vesicles 

Siiiii)l(' ciiUicU'ri/alion ol' llic cjaculaloi y duels is ^I'cally to l)e pre- 
t'cn-cd to llic injection of various solutions into llic intci-ior ot tlie ves- 
icles. Indeed, the cardinal value of cidlielerizalion of llie ducts lies in 
(lie dilatation of the ducts and therefore in the iiii])rove(l drainage 
whicli it assures to the inllannnatory products; to this con-esponding' 
de<;i'ee it nmst he evident that injections into the vesicles without this 
ini])roved di-ainage must l)e liazardous and even danft'erous. 

In ])oint of fact, it is absolutely impossible, at the present time, to 
detei-mine tlu^ exact location, form, and dimensions of the seminal 
vesicles, so that it is difficult to decide upon tlie quantity of fluid that is 
required to fill the vesicles completely. It, therefore, happens quite 
frequently that the injected fluid does not escape from the vesicle. It 
remains in the vesicular cavity diluting and disseminating the infected 
])roducts without bringing about any curative effect. On the contrary, 
the only time that I succeeded in injecting any liquid with certainty 
into a seminal vesicle (it was boric solution), an epididymitis devel- 
oped in the corresponding testicle two days later. But strange to re- 
late, this epididymitis passed off rapidly, without any fever and almost 
without i^ain, the patient having been made aware of the inflammation 
only by reason of the increased weight of the testicle. 

The cavity of the seminal vesicles can in no way be compared with 
the pelvis of the kidney, the normal capacity of which is usually the 
same and which is easily distended; when the limit of distention is 
]-eaclied it is distinctly and instantly felt by the patient on account of 
tlie pain which immediately follows. 

Finally, in conclusion, catheterization of the ejaculatory ducts is 
the only method to employ, — it facilitates drainage of tlie infected ves- 
icles, and it would appear that an^^ injections into the cavity of the 
vesicle must not be attempted until we are better informed than we 
ai-e today. 

[The editor assumes the liberty of supplementing the above re- 
marks by the following: Eecent improvements in technic have enabled 
us to secure splendid radiograms of the seminal vesicle, thus giving 
us exact information as to the size, shape and location of the organ. 
Likewise, Ave are enabled to detei-mine Avhether the inj(»cted fluid re- 
mains in the vesicle or passes through the ejaculatory ducts, by the 
simple expedient of injecting argyrol or any other colored fluid through 
the vas deferens, and inunediately thereafter passing a catheter into 
the bhulder. The colored (luid A\ill be found to have entered the blad- 
der via the ejaculatoiy ducts and the posterior urethra, if the ducts are 



130 



CYSTOSCOPY AND URETHROSCOPY 



jjatent. If the ducts are stenosed, the fluid will remain in the vesicle 
and the bladder urine will not be changed in color. If both sides are 
to be tested at the same session, different colored fluids are i^ijected, 
and drawn off separately from the bladder. The test is simple and ab- 
solutely reliable. — Editor.] 

Operative Technic: Catheterization of the Ejaculatory Ducts 

The descrii3tion and operative technic of my urethroscope having 
been thoroughly described above (see page 43) we shall not return to 
it at present. For catheterization of the ducts, a thorough urethro- 
vesical irrigation is given in order to cleanse the urethral mucosa. A 
long tube 13 centimeters in length is to be preferred. This tube Avill 
be chosen according to the caliber of the urethra, the largest diameter 
possible being selected. The tube is introduced directly into the pros- 
tatic fossette up to the anterior aspect of the verumontanum. Several 




Fig. 86. — Metallic bougies for catheterization of the ejaculatory canals. 

views may present themselves, and it is, therefore, fitting to refer to 
the illustrations that have already been mentioned in this connection. 

The simplest case is that in which there exists no median pros- 
tatic utricle, but on the lateral sides of the verumontanum on either 
side of the crest situated symmetrically two very distinct orifices are 
seen which mark the lower extremity of the ejaculatory ducts. In these 
cases the verumontanum presents an apjDearance similar to the diver's 
helmet (Fig. 79). It goes without saying that catheterization of the 
ejaculatory ducts in this type of case is comparatively simple. 

In catheterization, a straight metallic stylet is preferably chosen, 
and of the smallest possible caliber, to begin with. The urethroscope 
is turned about so that the lamp will be above, and not on the floor of 
the tube. The stylet is then directed horizontally along the entire 
length of the floor of the urethroscopic tube and easily brought up to 
the orifice which is to be catheterized. The "button-like" mouth of 



CATHETERIZATION" OF E.TACULATORY DUCTS 131 

tlie orifice is tlicii ix'iicl rated hy llic stylet in a iiiaTiiier similar to that 
employed in calliclci-izalioii of llic urctei'al oi'iliccs. Tliis entrance is 
facilitated hy ('in])l()yin^- lateral and vertical movements. The stylet 
havinft' entered llic orifice is inserted more deeply, carefully and ft'ently 
penetrating' from one to two centimeters and even up to six centimeters 
into tile inicrioi- of the ejaculatory duct. TC the slightest resistance is 
encountered, llie movement should l)e stop])ed. If these methods are 
(Muployed, there will usually be no pain nor much, if any, bleeding. 

The first stylet having been introduced, a second, of greater calibei- 
is employed in the same manner, and so on up to the largest size; care 
being always taken to follow the rules of ureteral catheterization: 
namely, avoiding any undue force or causing any bleeding of the 
mucosa. 

When the ejaculatory ducts can not be detected and with only a 
single median utricle present, a similar j)rocedure should be adopted. 
The point of the stylet is directed quite horizontally, so as to make it 
penetrate directly into the utricle. Then the handle of the stylet is in- 
clined (to the left for the left jduct, to the right for the right duct). 
Then after careful and gentle manipulation, the orifices of the ejacula- 
tory ducts will be discovered and penetrated as above described. 

Results Achieved Through Catheterization of the 
Ejaculatory Ducts 

Ever since I have adopted catheterization of the ducts as an in- 
dispensable and essential factor in the treatment of chronic spermato- 
cj^stitis, the results in my j^ractice have been entirely satisfactoiy. In 
these cases, the evacuation of the pathologic jDroducts retained in the 
vesicles has been accomplished by means of massage under conditions 
of improved drainage which the extensive dilatation of the ejaculatory 
ducts has made possible, and the results have been most satisfactory. 

The following case is one of the most interesting and instructive 
that has come under my observation, in which catheterization of the 
ducts was successfully performed with excellent results: 

The patient, M. G., aged forty years, was lirought to mc ])y M. Ilabibollah, an extern 
of the hospitals of Paris. Tliis j^atient had had three attacks of gonorrhea, almost all of 
llii'iu Iieing accompanied by various complications whieli included prostatitis and orchitis. 
^^■hen he visited me in August, 1912, ho had an abundant discharge wliich contained gono- 
cocci. His urine was uniformly turbid in all four glasses. Examination showed the exist- 
ciifo of a voi'v clear-cut case of chronic prostatitis; the opididymes presented hard indurations; 
the scniinal vesicles, especially the left, were painful lo the 1ouch. 

Treatment consisted at first of thorough urctlirovesical irrigations with permanganate 
combined with massage of the prostate and of the seminal vesicles. Dilatation of the urethral 



PLATE yil 

Fig. 1. — Normal appearance of the urethral hulh. TTie central figure takes 
on the form of a vertical cleft; the appearance of this region is highly 
characteristic. 

Fig. 2. — Pediciilated polypus of the bulbous region seen through the ure- 
throscope. 

Fig. 3. — Enormous cystic gland of Littre easily destroyed through vigorous 
dilatations. 

Fig. 4. — Lacuna of Morgagni chronicnlly inflamed. Its comi^lete disap- 
pearance can be secured only by the application of the electrolytic 
needle directly ujjon it. 

Fig. 5. — Soft infiltration of the urethra (typical urethroscoiaic aspect). 
The puifed up, oozing masses have an appearance similar to a mass of 
hemorrhoids. 

Fig. 6. — Stricture of the urethra. This figure is analogous to that of Plate 
VI, Fig. 2. It shows also the pasteboard-looking appearance of the 
urethral walls. 





/ 



Fig. 1. 



Fig. 2. 




Fig. .3. 





Fig. 4. 




Fig. 



PLATE VII 



Fig. 6. 



CA'I'IIK'I'HUI/A'nox OK K.I.\('|■l,A'^o|;^• Dl'CTS 1 .l.j 

ciiiiiil \v;is then i list il iitnl :it lirst with cimaciI shuikIs, l;itcr witli i-'raiK-U's t lu'iM'-liniiiclicd 
in iL;at iii;^ il ilatnr. 

Xcvcrlliclcss, till' Irfl vesicle was still extremely jciiiiful early iii Jaiiuaiy, JlH.';. in 
aililitinn, the hi'^hly iiii]H. riant fact was noted, that the contents of the left seminal vesicle 
could imt lie evacuated 1 ly massage vi<;oirius eiinii;;li to catiso sevcrc sharp pain. Ono day 
an attack (if epididymitis in tin hd't testicle was provuked hy a massage, n<i instrument lliat 
nii-lit liiive accounted for it haviiii; lieeii introduced into tin' urethra. 'riii)Ut,di tlu- attack 
ke|it him in lieil three or four days, the reaction \vas sli^^ht and the i ntlammation yielded to 
treatment quite icadily. This occurrence, c(Mul)iiied with the alio\c noted oliservation, clearly 
demoiistrat<'d that ma.ssagc was ]iot emptying the seiuinal vesi(de and that in consequence 
the ejaculalory canal was undoubtedly choked up with the debris. In these circumstances 
it was but natural that an attemjit be made to i-ecstablish a fice bimen in the duct. 

After all evidence of intlainmat ion in the canal had d isa[ipea reil, I made a iiretliro- 
scopic examiiuition on January 17, l!)lo, with a tube No. 2(3 caliber. The verumontanum was 
easily visible and because of the antecedent local treatment there was no inflammation or 
bleedinc;. 

The orifices of the cjaculatory ducts were found on the lateral sides of tJie verumontanum. 
On the left side, the orifice of the corresponding duct presented clearly, and I tried to cath- 
(Uerize it with a fine urethral sound No. 5; but the tip of the stylet immediately slipped on 
< he swollen and smooth surface of the verumontanum and refused to enter the interior. I 
then took a metal stylet with a studded tip and I noted that its end penetrated the orifice 
of the duct with the greatest facility. Tlie tip, being slightly conical, was at first arrested 
sonunvhat, but it soon entered the lumen of the duet for a distance of about one and a half 
centimeters. 

Immediately after this catheterization, the Idadder was filled with oxycyanide solution 
and the left seminal vesicle massaged. To my great surjirise and gratification, I found tliat 
massage hardly produced any pain. In additi-on, I saw that it was followed immediately 
by the evacuation of enormous purulent clots which ran into the glass held at the urinary 
meatus. Never before had massage produced such an evacuation in this patient. 

Following this procedure, not only was there no untoward local reaction, but the hard- 
ened left epididjTnis diminished in size and the urine became normal and absolutely devoid 
of shreds. This improvement continued, for the patient remained in the same satisfactory 
condition when I saw him ten days later. 

It seems then beyond any dou1)t, that in accordance with tliis 
oljsei'vation, catheterization of the ejacuhitory dncts may and shouhl 
be advised when the canals present a stenosis whicli prevents tlie nor- 
mal evacuation of the secretion products of the seminal vesicles. 

Catheterization has likewise produced the happiest results in dis- 
turbances of ejaculation whether they have been characterized by pain, 
or retardation, prematurity or bleeding. 

I have also had occasion to treat a colleague who for years mani- 
fested the tenderness which I have emphasized above and who also had 
become thoroughly neurasthenic because of the pains which he suffered 
after every coitus. He had a marked chronic ])ostt'rior uretliriiis ac- 
companied, as it always is, with a clear case of chronic spermatocystitis. 

The ti'eatment at lirst consisted of dihdation of tlie nretliia. This 
was followed by a thorough cleansing of the veruiiioiitainini, l!iii.< free- 
ing it of several little polyjDi and vegetations. This was accomi)lished 
by burning them with the ^-alvanocaiiterv. The tr(>atmoiit culminated 



134 CYSTOSCOPY A]<rD URETHROSCOPY 

in the catheterization and dilatation of the ejaculatory ducts. The last 
step alone relieved him of his suffering. The vague pains, constant 
and severe, which had made his life almost unbearable, also *disap- 
peared. This was undoubtedly a clear case of stenosis of the ejacula- 
tory ducts. Indeed though the smallest metallic sounds passed into 
the ejaculatory ducts quite easily, to the contrary, the larger sounds 
were passed only through the application of gentle force which pro- 
duced a sensation like that produced in urethral stricture. 

In other cases, phenomena of delayed ejaculation resulting in cer- 
tain types of sterility are sometimes observed. A man aged thirty 
years, married one year, was referred to me, by Alexandre, in January, 
1914, the complaint being that he was childless though very anxious to 
have a child. He also comj)lained of pain at the moment of ejaculation. 
Posterior urethroscopy revealed the cause of his troubles. 

The verumontanum was much deformed. Its anterior wall ap- 
peared eroded, and the prostatic utricle projected forward so that it 
resembled a uterine neck. This was evidently the cause of his sterility, 
for at emission there was no projection of the seminal fluid. The semen 
accumulated in the eroded pocket of the verumontanum and escaped 
from the meatus fully ten minutes after the orgasm. This anatomic 
deformity, very unusual by the way (Plate V, Fig. 1), explained clearly 
and surely the pain at the moment of orgasm as well as the sterility. 
Urethroscopic therapy consisted in destroying the anterior wall of the 
pocket of the verumontanum with the galvanocautery and as a result 
the ejaculatory pains disappeared entirely. 

In other cases the s^miptoms in connection with emission are less 
marked, but they exist, nevertheless, and the simple dilatation of the 
ducts is sufficient to cause their disappearance. I recall a patient, 
forty- three years of age, in whom the ducts were dilated three or four 
times; and after this treatment, he informed me that it had restored 
the virility of his youth and that never before had sexual relations been 
so pleasant. 

In still other instances, the ill-defined pains from which the pa- 
tients suffer during the sexual act, keep them from indulging, and thus 
tending to inculcate the belief that they are really impotent. As a re- 
sult, when these pains cease after treatment, they are perfectly happy 
to note the return of their virility. 

Finally, I have observed in a number of instances, ^^^thout being 
able to offer any explanation for the phenomenon, that the induration 
in the epididymis which followed an acute inflammation has disap- 
peared in many cases as the result of the systematic and methodic 
dilatation of the ejaculatory ducts. Doubtless this was due to the indi- 



ENDOURETHRAL TREATMENT OF TROSTATIC JTYPERTROniY 135 

rect effect piodiiccd l)y tlic draiiiaiic, tlius pci'inittiii,^ llic easy evaeua- 
lioii ol* tlic itircctiMl |)i-()(liicls ill tlic sciiiiiial vesicles. 

As a result of this study we may conclude tliat catlietci'izatiou of 
tlie ducts is a uiaueuvei- wliicli should be carried out as a routine treat- 
iiH'iit; riiitlicniioic, when pi-operly performed under favorable circum- 
stances, it lias never i^roduced the slightest inflammation or accident. 
AVe may safely say that catheterization of the ejaculatory ducts con- 
stitutes one of the finest achievements of modern urethroscoi^y. 

ENDOURETHRAL TREATMENT OF PROSTATIC 
HYPERTROPHY 

Freyer has demonstrated conclusively the undoubted value of 
transvesical prostatectomy in the treatment of hypertrophy of the pros- 
tate. There can be no doubt that this operation, in experienced hands, 
frees the patient from the thralldom of the catheter and from the dan- 
gers which accompany its use. But it is, nevertheless, true that while 
this operation is decidedly indicated in the case of a very large prostate, 
there are many instances in which the distress evidenced by the pa- 
tient is not of sufficient intensity to justify an operation of such ad- 
mitted gravity. 

It is admitted that the operation is demanded in complete reten- 
tion, in the presence of a very large prostate, or when the urine is in- 
fected. On the other hand, however, with incomplete retention of clear 
urine, varying in quantity between fifty and two hundred cubic centi- 
meters, but accompanied by increased frequency, pain at the beginning 
and end of urination, and diminution in the poAver of the stream, the op- 
eration is truly out of all proportion to the symptoms observed. It is 
in this type of case that the endoscopic treatment should be undertaken. 

This method of treatment has been applied by all observers who 
have taken up iDosterior urethroscopy systematically, and Cioldschmidt, 
one of the pioneers, obtained appreciable results. Unfortunately, as 
Harpster has pointed out,' Goldschmidt's instrument is very delicate, 
the lamp deteriorates easily, and in addition, hemorrhage is frequently 
l)roduced which comj^letely obscures the field of vision. 

The use of endoscopy in prostatic ]iy]>ertrophy is found to be com- 
pletely justified by the anatomic condition of the deformities which re- 
sult in the urethral canal. In the numerous researches which I have 
made in cases of prostatic hypertrophy, one fact has seemed to me to 
be constant; naincly, tliat in every case with retention of urine, my 
urethrosc()]uc tul)o, instead ol' ])en(^trating easily and directly into the 
prostatic urethra and the bladder, was always stopped at the neck of 



136 CYSTOSCOPY Al^B URETHROSCOPY 

tlie bladder by a prostatic bar. This bar is invariably located at tlie 
same place; i. e,, at the j^rostatic fossetto, Avhich is situated in front of 
the vesical neck and behind the posterior aspect of the verumontaimm ; 
in prostatic hypertrophy this space natnrally undergoes a decided 
anteroposterior lengthening. 

Consequently, the introduction of a straight tube into the posterior 
urethra is always impeded in prostatic hypertrophy by this prostatic 
bar, which prevents the tube from entering the bladder. It is then 
cjuite natural to expect that therapeutic efforts should tend toward the 
elimination of this bar so as to prevent the accumulation and retention 
of the urine; this is what Bottini sought to effect by blind methods with 
his galvanic incisor. This operation has been completely abandoned 
for the reason that it was done completely in the dark. 

The endoscopic method, on the other hand, is used under the con- 
trol of the eye and can be readily regulated both as to the intensity of 
the action, as well as to the extent of surface to be dealt with. The nu- 
merous endoscopic investigations which I have made, have given me 
the form and the size of this prostatic bar. Practically always it may 
be likened to a roof with two sloping sides. One of these slopes to- 
ward the bladder; in general, its degree of declivity is rather slight. 
The other slopes toward the urethra and its declivity is usually more 
al3rupt, almost vertical at times. Often, the top of the roof, which is 
the junction of the two sides, constitutes a more or less acute angle, but 
occasionally it is flattened in the form of a plateau. 

The treatment to be applied to the prostatic bar aims at its com- 
plete destruction both from the urethral and vesical directions. In 
this connection, it would appear at first thought that the urethral ap- 
proach is the easier of the two, but such is not at all the case. On the 
contrary, the jDrostatic bar is best attacked from the vesical direction 
with my direct vision cystoscope, and it is only at the end of the treat- 
ment Avhen it is advisable to complete the work on the urethral side, 
that the simple urethroscopic tube can be employed to advantage. 

REFEREiSrCE 

iHarpster: Prostatotomy by the Method of Goldsehmidt, Section on Genitourinary Diseases, 
Am. Med. Assn., 1913, p. 280. 

Operative Technic 

The operative technic is simple. For the oi^erative details, the 
reader is referred to page 229. The cystoscoxoic tube passes easily into 
the bladder in the vast majority of cases, facilitated by the elbowed 



i';.\i)()i"i:i;'i'i I i;ai, 'iin^AiAi lox'i' oi- i'kos'iwi'ic ii n i'i;i:'i'i;i)i'ir,' \.u 

<)i)tiiral<)r. ( )iicc iiil rodiiccd into llic liladdcr and llic urine willidi-awii, 
llic base of the Madder and llie two prostalie lolx's are iden1i(ie(|. 1'!ie 
normal ^^rooxc lielwcen llie lohes is folloWLMl, llie lube hein*;' witlidrawii 
,i;i'a<lually in llie nieaniinie. The \-esi('al slojjo of tli<! ])i'oslali(' har is 
now ()l)sei-\-e(l, and llie cauleri/alion Weft'iiis at tills point. A few di'ops 
of cocaine solulioii are deposited on the spot \\1iicli i< to he ;dtack'e(l. 
'Then havin.i;- waited a J'ew luiiiiites lor the anestlielic (d'fcet, tlio vesical 
asi)ect of the prostate is l)uriied willi tlie galvanoeaiitery point. 

Tlie operator tliiis digs a real ditcli in tlie prostate; and when it 
is done skilirully, it is very curious to note that there is little or no 
lieinorrhage. This cauterization produces just a little black, dry eschar 
froin ^v]^ch there is no oozing of any kind. As the cystoscopic tube is 
slowly Avithdrawn with the cautery in action, a real bed of fire is thus 
dug on the upper margin of the prostate until the tube reaches 
the urethra. 

This i^rocedure can not be completed at one sitting. Very deep 
cauterizations of the prostatic bar do not give satisfactory results; and 
the best results are attained when the applications of the galvano- 
cautery are made at fairly long intervals, the most satisfactory being 
al)out once in eight clays. With these precautions in mind, accidents 
will never occur. 

The first application is usually the most difficult, for the road has 
not yet been jorepared. The prostate is congested and bleeds easily 
at the slightest contact. With patience and the observance of due pre- 
cautions, really interesting results may be expected. 

The best way to determine that the operation is finished, i. e., that 
the jDrostatic bar has been completely destroyed, and that there is no 
further danger of a relapse, is to make an examination with an ordinary 
straight urethroscopic tube. If this tube passes without difficulty di- 
i-ectly from the urethra into the bladder, it indicates that the prostatic 
bar no longer exists and that the desired result has been attained. 

Results of the Treatment 

The i-esults are decidedly conclusive. Two principal facts are to 
he noted after this treatment. On the one hand, the complete disap- 
])earance of the bladder residue which was formerly present, and on 
the other hand, the increased force of tlie uiinary stream. The patient 
who before the treatment used to "urinate ou his jjoots," to nsi^ a 
hackneyed ]ihrase, now has a strong and normal stream. 

Among tlie cases which I have treated in this way, one is of ])ar- 
ticular interest. The patient, aged forty-seven, com})lained of difficulty 
in urination. This consisted first, in the fact that it took some time to 



138 CYSTOSCOPY AND URETHROSCOPY 

start tlie stream ; next, there was a diminution in the force and volume 
of the stream, and finally, that he suffered pain at the beginning and 
end of the act. Residual urine was clear and amounted to only^O c.c. 
Examination of the bladder with the urethroscopic tube was pre- 
vented by the existence of a large and well-defined prostatic bar. Onl}^ 
a tube Avitli elbowed obturator could be passed into the bladder. Treat- 
ment with the direct vision cystoscope extended over a period of about 
three months. At the end of that time as the result of many applica- 
tions of the galvanocautery, the urethra was completely freed of its 
prostatic bar. The straight urethroscopic tube easily passed from the 
urethra into the bladder. Not only was the patient relieved of his pains 
at the beginning and end of urination, but in addition he noted with joy 
that his stream Avas large and had an excellent projection; he uri- 
nated without any delay and his residuum was nil. 



CHAPTER IV 
CYSTOSCOPY 

Cystoscopy may be defined as the examination ol:' the vesical iiiu- 
cosa nnder tlie control of the eye witli special optical instruments, 
1liroui!,li tlio natural urinary passage and without surgical incision of 
llie bladder. Cystoscopy has become one of the most essential methods 
of exploration in urologic practice. Its indications are innumerable; 
its field of action is very great, for it includes all affections of tlie 
prostate, kidneys, and ureters. 

Without cystoscopy it is absolutely imxDossible at the present time 
to make a correct diagnosis in disease of the kidneys. Likewise we 
are enabled by means of meatoscopy, that is to say, the inspection of 
the orifices of the ureters, as well as through catheterization of the 
ureters and the collection of the separate kidney urines, to determine 
to a mathematical certainty whether one or both kidneys are diseased. 
Cystoscopy, therefore, not only furnishes the correct diagnosis in kid- 
ney affections, but what is still more important, it determines quite 
clearly the condition of the diseased organ and the indications for 
nephrectomy, when necessary. 

Again, the introduction of a catheter into the kidney pelvis, en- 
lightens us as to its capacity and makes it possible also to evacuate its 
pathologic contents. Antiseptic lavage of the pelvis can thus be per- 
formed; this method of therapy will usually improve and at times com- 
pletely cure certain mild cases of pyelonephritis. 

Still further, by the introduction of opaque liquids sucli as coUar- 
gol into the interior of the kidney pelvis, combined with the roentgen 
ray, w^e are enabled to obtain a clear radiogram of the pelvis and to 
deduce important diagnostic and therapeutic conclusions. 

In ureter disease, such as calculi, tumors, kinks, etc., cystoscopy 
permits the introduction of a catheter into the ureter, which tells us 
whether the latter is patent, obstructed, or kinked. I'he information 
of the presence of a foreign body; i. e., calculus, in the ureter, tlius ob- 
tained, will result in eliciting the proper indications for surgical inter- 
vention. 

In addition to the data derived ^^■ilhill the ureter, the ureteral 
catheter also furnishes other and highly iiii])()i-ianl inrorniation. By 

139 



140 CYSTOSCOPY AND URETHROSCOPY 

means of a metallic stylet within the ureteral catheter or the x-ray 
catheter impregnated so as to intercept the roentgen rays, we are en- 
abled to take a radiogram of the pelvis, as well as the direction and 
shape of the ureter. 

Finally, one of the most interesting and useful applications of 
the ureteral catheter from the therapeutic standpoint is found in con- 
nection with renal colic. I have often had the opportunity of observing 
during the crisis in nephritic colic, that a ureteral catheter introduced 
between the calculus and the ureteral wall on being rather suddenly 
withdrawn will initiate a downward movement of a hitherto stationary 
calculus and culminate with its subsequent exit from the ureter into 
the bladder. 

Cystoscopy is distinctly indicated in all affections of the bladder. 
It is only by the aid of this means of examination that the exact diag- 
nosis in bladder disturbances can be made. Thus, tumors of the blad- 
der, for example, are easily recognized, and it can not be denied that 
the precision of this method of diagnosis is far superior to the older 
clinical methods of palpation which always left the diagnosis vague 
and uncertain. Indeed, it is not too much to say that an experienced 
cystoscopist can often distinguish at a glance between a benign and a 
malignant growth, thereby affecting the prognosis considerably. 

When a stone is suspected, cystoscopy can be relied upon to give 
a positive diagnosis; for, although the presence of a large stone can be 
determined by the aid of a metallic searcher in the bladder, it is a fact 
that small stones may completely escape identification by this method. 
Likewise when small stones are encysted between trabecu]?e or in diver- 
ticulae, their existence can be discovered only through the aid of the 
cystoscopy The same is true after lithotrity, when it is necessary to 
make sure that all the fragments have been thoroughly evacuated and 
that there are no more in the bladder. Cystoscopy is invaluable for 
this purpose. 

Foreign bodies in the bladder can not really be diagnosed except 
by the aid of the cystoscope. When they have lain for a long period in 
the bladder, they are usually covered over with a layer of phosphatie 
salts which eventually transforms them so that they resemble a true 
stone. Cystoscopy makes the diagnosis exact by revealing their cor- 
rect size and shape. 

In all cases of chronic cystitis, cystoscopy is indicated for the pur- 
pose of determining the bladder condition and its etiology. In tuber- 
culosis, for example, the ulcerations resembling finger scratch marks 
are so typical and characteristic of this disease, that the real cause of 
the cystitis may be attrilmted to the Koch bacillus on the strength of 
these findings. 



CYSTOSf'Ol'Y 141 

Cystoscopy is also indicnic*! in disease of ilic jtrcjstalc In ])!•()- 
static liypertropliy in particular, cystoscopy makes il ])()ssihl(" 1o dis- 
tingiiisli not only the enlarged lobes, but also tlui true slia])e of llic 
organ and the amount of j^rojection of the lobes into the bladder. Tlic 
median lol)e and its various conformations can likewise be cardHliN 
studicMl. This method of examination is useful in many ways and 
should never be overlooked. As Marion^ has well put it: "Cystoscop}' 
enjoys the particular facult}' of revealing entirely unsuspected lesions 
at times, especially calculi and tumors, in cases in which llic Cunclional 
disturbances were not of sufficient gravity to attract special attention; 
in this manner cystoscopy offers exact information upon which spe- 
cific therapy may be based." 

In prostatic hypertrophy the normal aspect of the vesical neck is 
altered to a varia])le degree. There are important modifications in the 
reciprocal relations between the neck of the bladder and the ureters. 
Indeed, under the influence of prostatic enlargement the hypertroj^hied 
neck is drawn upward and backward, while the orifices of the ureters 
remain stationary. Consequently the distance from the vesical neck to 
the fundus is increased perceptibly. Cystoscopy also reveals the ex- 
istence of a vesical lesion which is always constant in i^rostatic hyper- 
trophy; that is, the presence of columns of trabecular disseminated over 
the entire surface of the vesical mucosa and especially at the fundus. 

Finally, cystoscopy finds one of its most frequent applications in 
the numerous urinary disturbances, b)^ enabling us to interpret the 
conditions which apply to the kidneys, bladder, ureters, or the prostate. 
We can, therefore, readily see wdiat a great field cystoscopy enjoys, and 
the numerous conditions in Avhich w^e may have recourse to the enlight- 
enment which this marvelous method of examination affords for the 
study of urinary disturbances. 

However, though we may regard cystoscopy as indispensable in al- 
most all diseases of the urinary apparatus, it may also be applied in 
many pathologic conditions quite distinct from the urinary tract 
proper. Thus in uterine disease, cystoscopic indications are numerous. 
During i3regnancy, for instance, the uterus causes the bladder to 
undergo important changes, which are referred to in a later chapter. 
In cancer of the uterus, the bladder condition will very often give ev- 
idence which may necessitate complete abdominal hysterectomy (see 
page 207). 

Previous to a laj^arotomy for uterine cancer or fibi'oid, it is very 
important to insert a ureteral catheter into each ureter so that it will 
act as a landmark or guide during the operation. This will ju'event 
injury to the ureters during the jDrocess of decortication or excision. 



142 CYSTOSCOPY AISTD URETHROSCOPY 

For want of this precaution, ureters have been injured by many general 
surgeons during this operation. In salpingitis, c3'stoscopy is also highly 
imiDortant, and I have been able to observe its usefulness in thist^condi- 
tion in several instances. In a case of right salpingoovaritis a patient 
in the service of Arrou at the Hopital cle la Pitie, also complained of 
clearly defined pains referred to the right kidney; and considering the 
grave accompanying conditions, such as increased temperature and 
poor general condition, it was practically impossible to determine clin- 
ically whether the symptoms observed were due to the salpingitis or to 
a pyonephrosis. Cystoscopy showed that the right ureteral orifice did 
not functionate properly and did not present normal clean-cut urinary 
ejaculations. In addition it showed that this ureter was impermeable 
to a No. 6 catheter, thus forcing the conclusion that this canal had be- 
come constricted somewhere. The ^Datient was i3ut to bed with ice ap- 
plications to the abdomen. This treatment was followed by excellent 
results, for as soon as the inflammatory condition of the right tube 
improved, the renal troubles disappeared completely and the pains did 
not return. 

In. other eases cystoscopy enabled us to locate the openings of pus 
collections in the bladder of salpingitic origin. The cystoscopic ap- 
pearance of these vesical perforations has been drawn from nature in 
Plate X, Fig. 2. Reports of two cases follow. 

Case 1. — Supinirative salpingitis luith localised peritonitis perforating the bladder. A 
woman, L. E., aged twenty-uiue, was sent to me at the Broca Hospital, bv Arrou, on December 
13, 1912, with purulent urine. Pus had suddenly appeared in the urine in January, 1911, and 
from that date had never disappeared. Cystoscopic examination showed a healthy bladder 
throughout ; however, a large fleshy pimple was observed on the base of the bladder, behind 
the ureteral oritices. This large mass obscured an orifice through which pus was exuding ; and 
which admitted a catheter No. 5 for a distance of about one centimeter. The ureteral orifices 
appeared to be normal. 

This was undoubtedly an abscess which had ruptured at the fundus of the bladder. 
Operation was performed by Arrou at the New Pitie Hospital on December 19, 1912. In 
the course of the laparotomy he was able to determine that there was a perforation of the 
bladder at the fundus and that the pus was emanating from an enormous salpingitis situated 
in the lower pelvis. Both tubes and the uterus were removed. 

Case 2. — A woman, B. B. J., aged twenty-nine, was referred by Arrou, on March 25, 
1911, at the Broca Hosj)ital, because she had very purulent urine. Double catheterization of 
the ureters showed that the two kidneys were secreting perfectly clear urine and that the 
pus could not possibly come from that source. Vesical cystoscopy, on the other hand, showed 
that while the entire vesical wall was generally normal, the base presented an edematous 
plaque studded with tender papules. This was probably the site of a vesical perforation. 
Vaginal examination revealed an enormous salx^iugitic mass which was attached to the uterus. 

Perforation of the Bladder by an Abscess of the Iliac Fossa. — 

Cystoscopy is also useful in cases of iliac abscess, as the following case 
illustrates : 



CYSTOSCOPY 



143 



On Ainil 1, liHi'i. M. Ic Mninc, ;m iiilcin in tlie servico of R<k-1i:u<1 at tho Ilopital St. 
Ldiiis, r('(|U('st('i| nil' tn cxiuniiii' ;i initicnt whu liml ;i fovoro pyui-i;i, }(i'f)1i:i1ily of kidnoy origin. 
On A[iril S, I s;i\v llir |i;iticn1, ;i \v(ini;iii iil^i'iI 1 li i it y-cit^lil . wlm liml ciitrriMl tlic hospital on 
Ft'hruary 19, li)()!t, conipliiiiiiiig of paiii.s in tho riyiit iliac fossa; she had an aftornooii tcni- 
[iciatnie of r!S.S° C On January 5 procodinj^j, she had given liirth to a healthy ehiM. On 
eiitraiu'c to the li(is|iital slic liad clear urine, liut a few days later her urine suddenly heeanie 
(|uit(' ]iurul(Uit, with |inin nl tlie end (d' urination. SimuUnnrnusly the teiniieratiii-e dropped 
to :\7 C. 

In spite of vesical lavage with nitrate of silver, the pyuria did not diniiiush. In addi- 
tion there was a jiainful swelling in the right gioin, suggesting the possibility of a purulent 
collection at the right Inoad ligament which had worked itself down to its lower margin 
liy following the lound ligament. With my direct vision cystoscope I saw that the bladder 




Fig. 87. — Star-shaped cicatrix resulting from a perforation of the bladder, due to an abscess of the right 

iliac fossa. 



was normal over almost its entire area. Both ureteral oritices were normal and gave no evi- 
dence of inflammation. However, at the junction of the posterior and right superior walls a 
little fierydooking mass was visible, about the size of a franc piece, and made up of fleshy 
looking papules which bled easilj' on contact. These papules admitted the introduction of a 
ureteral catheter provided with a metallic stylet to the extent of about one centimeter. Just 
as soon as the stylet was withdrawn, however, a mass of thick pus, like custard or cream inun- 
dated tho entire bladder; this showed the undoubted existence of a vesical perforation, which 
was quite contrary to the original diagnosis of renal pyuria. 

Late in April, 1909, the skin in the region of the right groin became red and inflamed, 
and when the tumefaction which had formed there was incised, a profuse pus collection was 
evacuated. It was then diained for about fifteen davs. Immediatelv after the incision of 



144 



CYSTOSCOPY AND URETHROSCOPY 



this abscess the urine cleared up and remained quite clear when the wound had healed. I 
examined this woman a second time on May 19. The urine was still clear, and the bladder 
perfectly normal throughout ; and instead of the perforation which was visible six weeks 
previously, there was simply a small air-tight scar (Fig. 87). *► 

In diseases of the intestinal tract, especially cancer, cystoscopy 
will very often verify the presence of adhesions or ^perforations which 
may he present as the result of the neoplastic process. In appendicitis 
also, cystoscopy may he useful in avoiding errors in diagnosis Avhich 




Fig. 88. — View of a vesical perforation of an adjacent abscess. 



may he harmful. It is well-recognized that it is often difficult to deter- 
mine the clinical diagnosis hetween appendicitis, ureteral calculus, 
floating kidne}^, and renal colic. By studying the ureteral orifices we 
can learn whether they are normal or otherwise; if they are not normal 
in appearance, the diagnosis points to a lesion of the ureter or kidney, 
thus eliminating the appendix entirely. 

In appendicitis I have had occasion to observe appendicular ab- 
scesses which perforated the vesical wall and opened into the bladder. 
The following is a report of one of these cases : 



CYSTOSCOPY 145 

Mnic C. B., aged fifty-four years, piitorcd llic lIAjiilsil S.iiiit Louis on October 24, 1908, 
in tlic scrN'icc of IJocliai'il. Some ilnys proviously, slic iidliccd tli:il licr iirino siuldonly linr-amf 
I'xticincly liiiliiil and muddy and sIic complained in aildilinn, ai' sc\ri-c imin on niination. 
Sli(\ was i)ale and very weak while lier tcmpei'aturc osfdllated around .''.9'^ C On examination 
il was noted llial llie ri<^ld kiilney was clearly lowered and easily jialpiiblc bimanually, and 
seemed 1(i lie sensitive to tlie toiudi. The pain provokeil liy 1he iiand placed on the anterior 
ahdonunal wall extended to tlie riyiit side of the abdomen, whi(di preseided mai-ked museular 
resislaiicc extending to the right iliac fossa. The left kidney could not be paljiated. In the 
jucsence of such unmistakable symptoms, the diagnosis based on the ]iurulent mine, the pain 
and the hiniaiiual examination -of the right kidney seemed unmislakahle ; it was quite ap- 
parent we were dealing with a large right pyonephrosis. 

Before operating on the right kidney, howevei', M. Bodolec, the intern on duty, asked 
lue to examine the patient and to secure the separated urines. I examined her on Octoljer 27. 
The vesical urine obtained through a catheter was horribly fetid and muddy and had the 
color and consistency of pus. The vesical capacity was normal, and measured at least 200 
e.c. After thorough lavage of the bladder, I applied my separator without any difficulty 
and after a few moments, and quite contrary to all expectations, the right side of the 
separator produced a perfectly clear urine, the same as came from the left side. During 
the first ten minutes the right tube constantly gave forth clear urine, but at the end of that 
time, a heavy discharge of thick, creamy pus appeared on that side. A little while later, 
clear urine again appeared on this side. The appearance of the right tube was quite cliar- 
acteristic: below, clear urine; in the middle, pure pus; above, clear urine. On the left side, 
the urine remained clear throughout the entire examination. 

Analysis of the separated urines was made by the staff intern in pharmacy with the 
quantities of urine for both kidneys about the same: 





Bight Kidney 


Left Kidney 


Bladder 


Cryoseopic Point 


—0.48 


—0.54 


—1.03 


Urea (per liter) 


4.80 gm. 


5.25 gm. 


6.75 gm, 


Chlorides (per liter) 


2.70 " 


2.80 " 


3.10 " 



1 le result of this analysis showed that there was very little difference between the two 
kidneys and that the enormous flow of pus in the right tube of the separator did not seem 
consistent with the relatively satisfactory kidney examination. We were then dealing with 
something extrarenal and the right kidney could not be held responsible for the profuse pyuria. 
I, therefore, suggested that a cystoscopic examination be made. 

The following day, October 28, I applied my direct vision cystoscope. I saw that the 
bladder generally was normal, the ureteral 'orifices did not differ from one another, and that 
the base of the bladder was but slightly inflamed. But behind the plane of the ureteral 
orifices to the right of the medial line, a gaping circular orifice was seen; it had clean-cut 
edges and thinned walls and was about eight millimeters in diameter. From the lumen of 
this opening, purulent masses issued. 

These cystoscopic findings fully confirmed the tentative diagnosis and explained very 
clearly the data previously furnished by the separator. The pyuria was certainly due to a 
perforation of the bladder following an extraneous abscess which had ruptured into it. The 
data furnished by clinical observation exclusively was entirely wrong; the cystoscope proved 
',)eyond doubt that the suspected right kidney was unaffected and that the pyuria came from 
an adjacert abscess. 

This diagnosis was later confirmed at autopsy, which was performed by M. Bodolec. 
The vesical perforation was found exactly in the spot which had been indicated by cystoscopy. 
Hint is to say, about five centimeters behind the right ureteral orifice. The edges of this 
lipeiiing W'cre perpendicular and did not seem to be the seat of inflammation: the bladder wall 
at that point was of normal thickness. 

This perforation cominunieated posteriorly with a vast pocket filled with pus, the origin 
of which seemed to be an appendicular abscess. In point of fact, the intestines were matted 



PLATE VIII 

Figs. 1 and 2. — Cystic and purulent Littre's glands. Looking at this pic- 
ture one can readily understand the therapeutic importance of forcible 
dilatation, which breaks wp these inflamed glands. 

Fig. ?,.—Morgagni's lacunce and Littre's glands chronically inflamed. 

Fig. 4. — Littre's glands chronically inflamed. 

Fig. 5. — Pathologic aspect of the anterior surface of the verumontanum 
chronically inflamed for years. Exemplifying the ''mirror of the 
seminal vesicles. ' ' 

Fig. 6. — Enormous polypus at the external orifice of the female urethra. 



4 





Fig. 1. 



Fig. 2. 





Fig. 3. 



Fig. 4. 




Fig. 5. 




PLATE VIII 



Fig. 6. 



AXATOMK' COXSIDKRATIOXS 147 

tiJUcdirr t(i\v;inl tlic riylit siilc nt' (lie |irl\ic (•;i\ily nml ;i|i|h';i ; cl lo l,r ailhricnl (n 1 lie ;ii| j:ii-ciit 
pclvir (iil;:iiis. 'I'liis i lit est i ii:i I iiiiiss imimminI ;iiiiI (iI iscii i nl llir 1jI:ii|iIit .•iikI iitr'rus foniiiletcly 
:iihl it \v:is iiiily liy st'|i!i i :it i ii^ tlirsc aillicsidiis tliiil ;i liiij^c |Minilciit |r.M-kct situiitf'd iihovc 
mill to tlic riylit nl' (lie lihiiMi'r was d isc(i\crci| ami sii Ii^r(|iicii1 ly (ipriird. The iifcnis am! its 
ailni'xa were pci iVrl ly mniiial. 

Oil the right side, the ureter was slightly compressed hy Iho presence of the pus pocket 
and was slightly dilated below llic point of fonstriction. This explains llic somewhat int'(M-ior 
fuiH-1 ioiial ]i('r1'oi niaiii'o of the rij4lil ]<idiicy as (-oiii|ia i cd willi tlic Icl't. On examinativin, liolli 
kidneys were found iiractically alike in all i-esjiects ; 1 iiey each weighed about l^;") grams and 
were rather pale and soft. Neither of them showed any evidence of hydronephrosis. The 
psoas, the lioiiy liiim of the ]iel\is and the vei'lelii'al rojuiiin were without any lesion whatever. 

From this study, tlie following conclusions may be drawn: 1. In 
tlic diagnosis of pyuria, it is absolutely necessary to regard tl'.e clinical 
(lata alone as insufficient, inasnmcli as it may lead to serious eiTor; the 
! Methods of instrumental exploration and examination which provide 
exact information should also be employed. 2. Cystoscopy should al- 
ways be i:)erformed, in addition to the separation of the urines. 3. In 
IDcrforming endovesical separation of the urines, it is very important to 
study carefully the method of urinary ejaculation and the way in which 
the j)us and urine make their exit from the respective tubes of the 
sejDarator. 

REFERENCE 

iMavion: La Cystoseopie dans I'hypertrophie de la prostate, Jour, d 'Urologie, 1912, ii, p. ?,?,. 

ANATOMIC CONSIDERATIONS 

In order to become familiar with the bladder with the aid of 
cystoscopy, whichever instrument may be emi^loyed, it is essential to 
establish fixed and identical landmarks. With this purpose in mind, 
the bladder may be divided into four principal parts: 

The first consists of the superior wall, vertex or dome, which ex- 
tends forward from the bladder neck and becomes continuous with the 
second portion or vesical base, after having described its curve with an 
anterosuperior convexity. This is the largest of the four bladder divi- 
sions. 

The second is made up of the posteroinferior wall of the bladder, 
or vesical base (bas-fond) (fundus). It is continued upward and 
l)ackward with the vesical dome. It is separated from the third por- 
tion by the interureteral ligament or muscle, which extends between the 
two ureteral orifices, thus separating the fundus from the trigone. This 
interureteral ridge is one of the most iiii])()rtaiit hiiidiiiarlxs in cystos- 
copy for it gives the opei-ator his l)earings, so that he can tell in which 
region of the bladder his cystoscope happens to be, to what depth it has 



148 



CYSTOSCOPY AND URETHROSCOPY 



penetrated, and Avhicli segment of the bladder he has under observation. 

At times the interureteral muscle manifests itself under the form 
of a transverse cord which elevates the wall of the bladder. J^ other 
times it is hardly noticeable at all, and forms onlj^ a transverse coil or 
fold barely visible. It may be described as follows : A median portion, 
not very well marked, and two lateral portions Avhich surround the or- 
ifices of the ureters like an elliptical pad or swelling, and which deter- 
mines the prominence of the ureteral orifices above the vesical floor, 
this prominence varying in different individuals. 

According to the investigations of Uteau^ the total length of the 
interureteral ridge averages 3.27 centimeters in the male, and 2.68 cen- 
timeters in the female. The distance from the middle of the ridge to 
the neck of the bladder averages about 2.05 centimeters. 




Fig. 89. — The floor of the bladder, showing the proximal portion of the ureter (after L,. Testut). 

The third subdivision of the bladder consists of the bladder trigone 
or the triangle of Lieutaud. The three angles which bound it are 
formed by the internal orifice of the urethra and the two ureteral or- 
ifices, one on either side. This portion of the bladder is separated from 
the fundus, as we have already seen, by the interureteral ligament or 
muscle. It is continued forward to meet the fourth part, or vesical 
neck. On the lateral portions of the trigone and immediately adjoin- 
ing the eminence formed by the termination of the interureteral ridge 
around the ureteral orifice are found the so-called ' ' paratrigonal 
]~;lanes." At this point the vesical mucosa is often very thin and trans- 
parent, so that the course of the ureters may sometimes be observed 
for a variable distance. 

The vesical trigone is by far the most important portion of the 



ANATOMIC CONSIDEKATIONS 149 

bladder from tlie cystoscopic standpoint. Indeed, because of its situa- 
tion immediately adjacent to the orifices of tlie ureters, the trigone 
iiatui'ally feeLs the first effect of iiifhuiiiiiatious involviiii;' tlie kidneys, 
wliich empty their pathologic products at this point. 

We have already seen that the distance between the two ureteral 
orifices is equal to the length of the interureteral ridge itself. Consid- 
ering the distance from the neck of the bladder to one of the ureteral 
orifices, we find it generally averages 2.75 cm. in the male and 2.27 cm. 
in the female. We also find that the distance from the ureteral orifice 
to the median line averages 1.58 cm. in the male and 1.34 cm. in the 
female. 

The fourth portion consists of the neck of the bladder or the inter- 
nal vesical sphincter. The neck of the bladder offers entirely different 
cystoscopic appearances, depending on whether the indirect (pris- 
matic) or direct vision instrument is used, and also as to whether the 
male or female bladder is being examined. The presence of the pros- 
tate in the male causes many diverse and variable modifications in the 
appearance of the bladder neck. This portion of the bladder will be 
considered in greater detail later (see j)ages 198 and 247). 

EEFERENCE 
lUteau: Ann. d. nial. d. org. genito-urin., 1905, p. 241. 

Normal Color of the Vesical Mucosa. — The normal color of the 
bladder mucosa is clear yellow or rose yellow, but this is subject to 
many modifications and variations according to the degree of fullness 
of the viscus; indeed, the slightest degree of inflammation of the mu- 
cosa is made evident by the appearance of a more or less reddish tint. 
Normally, the mucosa is smooth, glossy, and uniform in texture; but 
when it is inflamed, it becomes dull, velvety and mucoid in appearance. 
Cases are often encountered in which numerous depressions or recesses 
appear, which give a more or less trabeculated appearance, depending 
on the degree of inflammation present; the bladder in this condition is 
then described as columnar or trabeculated. 

It is of the utmost importance to recognize the vessels of the nui- 
cosa which are made visible through the cystoscope. In the normal 
bladder the arteries are seen principally; these appear in the form of 
arterial clusters and vascular arborizations, decidedly attractive in 
appearance and most abundant in the region of the vesical neck. They 
are often arranged in the form of a star. In other ])arts of the bladder, 
their appearance is practically the same as that which ()])litlialiiioscopy 
reveals at the fundus of the eye. 



150 CYSTOSCOPY AND UEETHROSCOPY 

The veins are nsually not visible. They appear like dark lines of 
a grayish blue color. In the aged, rather thick, superficial veins are 
often seen, of dark color and varicose appearance. 

URETERAL MEATOSCOPY 

Meatoscopy is the study of the ureteral orifices in the bladder as 
seen with the eye through the cystoscope. From the particular aiDpear- 
ance of the ureteral orifices we may obtain information which may 
determine whether there are lesions in the ureters or disturbances in 
the corresponding kidney. 

The points to be examined particularly are the ureteral orifice, 
the character of the ureteral emission or ejaculation of urine and the 
situation of the ureteral orifice in relation to a lesion of the bladder, a 
vesical tumor, for example. Meatoscopy has been studied particularly 
by E. Hurry Fenwick, who has devoted a great part of his work^ to 
this subject, and also by Edgar Garceau.^ 

Examination of the Ureteral Orifices 

In order to identify the ureteral orifices, the distance from the 
neck of the bladder to the ureteral plane should be borne in mind; this 
has already been referred to (see page 148). But the most imx^ortant 
guide in finding the orifices of the ureters readily is the interureteral 
muscle or ridge; this applies quite as well with the indirect (pris- 
matic) cystoscope as with the direct vision. This is undoubtedly 'the 
best guide for finding the ureteral orifices. 

[In teaching cystoscopy to American students, the editor has 
found a most valuable guide in the location of the ureteral orifices, by 
comparing the vesical field of vision to the face of a clock, and refer- 
ring to the segments which correspond with the numbers on the clock's 
face. In this way, it is found that the ureteral orifices are usually lo- 
cated so that they correspond with the number YIII or IX for the right 
ureter, and III or IV for the left ureter. Thus it is easy to describe the 
orifice as being near III on the clock, or IX, as the case may be. This 
always makes it easier for the student, and even for the experienced 
operator, to locate the orifices, especially when they are very small. — 
Editor.] 

Aspect of the Ureteral Orifices. — In the normal state the orifices 
of the ureters may present a considerable variety of form, size, and 
situation. In the vast majority of cases, the orifice is seen as a semi- 
elliptic projection clearly distinguished from the vesical mucosa; it is 



URETERAL MEATOSCOPY 



151 



formed liko a small nipple, cone, or eminence, more or less i-oundcd and 
with a cleft in its center or summit. 

This cleft is usually simply a line; in oth.er instances, it is in the 
form of a crescent or a comma. Occasionally it reseml)les a little 
l)()utoiniiere, similar to a pair of half-closed eyelids. Aoain the orifice 




Fig. 90. 



Fig. 91. 



Fig. 92. 





Fig. 93. 



Fig. 94. 





Fig. 95. Fig. 96. Fig. 97. 

Various Aspects of the Ureteral Orifices (Knorr^ and Fe.n\vick=). 

Pig. 90. — Normal ureteral orifice projecting like a papilla (Knorr). 

pig. 91. — Normal ureteral orifice in the shape of an oblique cleft (Knorr). 

Fig. 92. — Large, open ureteral orifice (Knorr). 

Fig. 93. — Ureteral orifice shaped like the beak of a clarionette (Knorr). 

Fig. 94. — Ureteral orifice lengthened into a sharj) line (Knorr). 

Fig. 95. — Narrow ureteral orifice with thickened lips, indicative of a mild pyelitis (Fenwick). 

Fig. 96. — Arch-shaped oxifice indicative of a ureteral dilatation (Fenwick). 

Fig. 97.— Golf-hole-shaped ureteral orifice, indicating a destruction of the kidney, as observed in 
renal calculus and tuberculosis (Fenwick). 

iR. Knorr: Die Cystoskopie und Urethroskopie bcim Weibe, Berlin, 190b!. Urban and Schwarzen- 

-Fenwick: Ureteric Meatoscopy in Obscure Diseases of the Kidney, London, 1903, Churchill. 



berg. 



152 CYSTOSCOPY AXD IJEETHEOSCOPY 

looks like a scratch mark, sometliing analogous to the imi^ression of a 
horseshoe on hard snow. It may also be seen in the form of a little 
circular orifice or a small oval fossette; and finally, it may res^nble a 
more or less gaping chasm. 

The orifice is sometimes of very small caliber congenitally; that 
is, it exists at the time of birth similarly to the congenitally small ure- 
thral meatus. This anomaly may remain unnoticed for a long period of 
years; it is frequently the cause of accidents associated with ureteral 
and pyelitic dilatation, which at first appear inexplicable. The path- 
ogeny of these accidents is soon revealed by the cystoscopic discovery 
of this malformation. 

The ureteral orifice may also be the seat of a pathologic atresia, 
owing to the presence of a vesical tumor, and it is then easy to under- 
stand the importance of meatoscopy in such cases. Indeed, in such a 
case, a stricture of the ureteral orifice aoII bring on a retrograde dila- 
tation of the ureter and of the pelvis and will cause renal pains in the 
corresponding kidney. Through meatoscopy, we are enabled to deter- 
mine the real etiology of such pains and are thus prevented from 
wrongly subjecting the kidney to treatment when the bladder is really 
affected. 

Apart from the matter of size, there are a number of other peculiar- 
ities which the ureteral orifices may present. In order to appreciate 
these peculiarities it is generally necessary to compare the tAvo orifices, 
one with the other; and in this connection, it is well to note the follow- 
ing facts which have been fully described by Fenwick. 

A ureteral orifice ma}^ be congested and present marked vascular- 
ization. This is an indication of hyperactivity of the corresponding 
kidney and of a pyelorenal inflammation extending toAvards the blad- 
der. Allien the orifice is turgid and elongated and the lips are in- 
flamed and congested, dilatation of the pelvis and of the corresponding- 
ureter is indicated. AYhen the ureteral meatus is ulcerated and pre- 
sents one or more ulcerations with irregular and jagged edges like a 
finger scratch around its orifice, and when its orifice is situated in the 
base of this ulceration, we are dealing with renal tuberculosis (Plate 
XVI, Fig. 1). 

When the ureteral orifice takes on an arched appearance resem- 
bling an oval arch, we must think of the first phase of a ureteral dilata- 
tion which has extended from beloAA' in an upward direction. A ure- 
teral orifice presenting a perfectly circular opening indicates a dilated 
ureter. Fenwick^ likens this picture to a "golf hole" (Fig. 97). In 
this case the orifice is round and the edges small. Its dimensions vary 
between the small letter "o" and a capital '^0," but its lips are never 



UKETERAL MEATOSCOPY 153 

iiillaiiu'il. Ilowcvci', tlic conroi-iiialioii of a uiclci'al oi-ilicc is not always 
a certain indication of the degree of dilatation of tlic uiclci-, for tliis 
canal may liave the dimensions of a chikl's small intestine and never- 
theless the orifice of the ureter may be but very little dilated. When, 
liowever, in addition to this appearance, the lips of the orifice are red 
and indamed, it indicates that the corresponding kidney is markedly 
pyelonephritic and that tlie renal parenchyma has been fundamentally 
changed. 

When the lips of a dilated, round, ureteral orifice are of a dirty 
white color, as if they were coated with wax, while the surrounding tis- 
sues are red, it is an indication that a periureteritis is present. The 
ureter then appears like a thick red cord. This appearance is met with 
es23ecially in ureterorenal tuberculosis. A ureteral orifice may be small, 
wrinkled, distorted, or irregular. It is then an evidence of a pre- 
existent erosive ureteritis. Occasionally the ureteral orifice is sepa- 
rated in two by a little bridge of tissue ; this is generally the result of 
the cicatrization of a preexistent ureteral ulceration. 

A ureteral orifice with a papillomatous appearance indicates the 
presence of a chronic irritating discharge from the ureter. A similar 
arrangement may be seen in Plate XII, Fig, 3. It was observed in a 
woman with acute uric acid diathesis who passed very little urine and 
this in high concentration. The ureteral orifice was chronically in- 
flamed, particularly that portion which was traversed by the irritating 
urine which had left its mark by an accompanying inflammation. 

In renal lithiasis the slightly conical eversion of the orifice is fre- 
quently found. Prolapse of the ureteral orifice may be more or less ac- 
centuated. Sometimes it exists only at the very moment of ureteral 
emission and resembles the rectal prolapse seen in defecation. At other 
times it may be more accentuated, j^resenting the appearance of a real 
hernia of the ureteral mucosa, even simulating at times, a vesical tu- 
mor. The eversion of the ureteral mucosa like an inverted finger of 
a glove diminishes by just so much the dimensions of the orifice and 
in consec|uence may result in more or less retention of urine higher up 
in the ureter. 

Retraction of the ureteral orifice is brought about by the fact that 
tlie ureteral orifice is situated at the base of a deep depression of the 
bladder, instead of making its normal projection like a nipple within 
the bladder (Pig. 98). 

In these cases it is well to remember that the ureter which is 
chronically infiamed and shortened thereby causes retraction of its ori- 
fice. It is, therefore, reasonable to assume that this arrangement of the 



154 



CYSTOSCOPY AND URETHROSCOPY 



orifice indicates the existence of a severe pyonephrosis of the corre- 
sponding kidne}^ 

Edema of the ureteral orifice is met with very frequently*ln the 
course of renal or ureteral lithiasis and especially coincident with or 
immediately following renal crises. This accounts for the fact that 
catheterization of the ureter is often very difficult in these circum- 
stances. Indeed, in these instances the orifice is sometimes hardly vis- 
ible, being lost in a mass of bullous edema resembling small whitish 
balloons heaped up one against the other and presenting thin reddish 




Fig. 98. — Retraction of the ureteral orifice, the result of an inflammation of the ureter. 



furrows and vascular arborizations. This edema of the orifice is often 
the indication of renal tuberculosis. However, it must not be con- 
fused with the cystic dilatation of the lower extremity of the ureter 
which consists of a single swelling of rather considerable size and cov- 
ered over with a few small vessels. 

Intravesical dilatation of the lower extremity of the ureter has 
been carefully studied by Pasteau,* Albarran,^ and Bazy.^ This dilata- 
tion can be determined only by a cystoscopic examination and appears 
in the bladder in the form of a sessile tumor more or less fully pedun- 
culated and implanted in the ureteral zone. The surface of this cystic 



URETERAL MEATOSCOPY 



155 



<lilatation is most often snioolli and coNci-cd oxer hy a noi-mal mucosa, 
in wliicli (iiic \-as<MiIai- achorizalions ina_\- Ix- seen ( l^'i^', 99), 

Occasioiuilly tlie in-etei-al orifice is situated at tiie suniniit of the 
swelling, but at other times it is almost invisible, and tiie diagnosis 
then Ix'comes more difficult. Howevei', when the tumor appears near 
tlie ureteral zone, it is always well to lliink' of this condition. More- 
over, when the tumor distends itself rhythmically and periodically at 
the moment of ureteral emission, the diagnosis is quite clear. On the 
other hand, the diagnosis is not a difficult one when there is a single 




Fig. 99. — Prolapse of the lower extremity of the right ureter; the ureteral orifice cannot be seen (Bazy). 

tumor, smooth, firm, and covered with a healthy mucosa, in the ureteral 
zone. It can hardly be anything else. 

Bazy has explained the formation of cystic dilatation, which he 
believes, ought to be designated a j^rolapse of the ureter in the blad- 
der. According to this author, this affection is due to the existence of a 
stricture of the ureteral meatus; that is to say, from the pathogenic 
point of view, it seems that it may be a congenital lesion although the 
unfortunate symptoms in most instances do not become numifest until 
adult life. 

If the ureter above the contracted ureteral meatus is subjected to 
violent contractions, proUqjse ndglit follow in the same manner as oc- 



156 CYSTOSCOPY AND URETHROSCOPY 

curs in prolapse of the rectum resulting from liemorrlioids. The ef- 
fort made by the ureter to empty its contents on the one hand, and the 
difficulty of the passage of its contents through the contracted itreteral 
orifice on the other, constitute the predominating factor in the devel- 
opment of these cysts. If the contents are liquid, the chances of pro- 
lapse are small, but if the ureter is trying to expel a solid body like a 
blood clot or a calculus, the effort of expulsion is greater and the 
chances of prolapse will be correspondingly increased. 

In certain cases the stone descending the ureter strikes against 




Fig. 100. — Prolapse of the ureter, with ureteral calculus, and capped by a secondary vesical calculus (Bazy). 

the crest of the ureteric orifice. Little by little, as it increases in vol- 
ume it pushes the ureteral walls backward and around it according to 
its development, and thereby determines the dimensions of the ureter 
and the cavity in which it is lodged. As Bazy has observed, it is not 
the cavity Avhich controls the size of the calculus; the dilatation above 
is necessarily secondary to the existence and the development of cal- 
culus. Albarran has cited a case in which the simple pressure of the 
ureteral sound was sufficient to reduce the prolapse of the lower ex- 
tremity of the ureter, which thus returned to the normal completely. 
These cystic dilatations of the lower extremity of the ureter gen- 
erally yield to surgical treatment, which should always be transvesical. 



URETERAL MEATOSCOPY 



157 



AVlion tlie tuinoi- is reached, it is opened freely, and tlie calculi re- 
moved, if tliere be any. 

AiioiTialies in tlie nioutli of the ureters are not rare; the two illus- 




Fig. 101. — Aiii)ni:il\' of the ureteral orifices, drawn from nature. On the left, are two ureteral urilkes; 
on the right, the ureteral orifice is normal. 

trations which are here presented show rather interesting anomalies 
which I have myself observed. In one case (Fig. 101), there were three 
ureteral orifices. On the right side, the orifice was in its iDroper place 




Fig. 102. — Anomaly of the ureteral orifices, drawn from nature. Two ureteral orifices, on the right 

side, none on the left. 



and qnite normal; bnt on the left, there were two ureteral orifices, one 
above the other, in the direction of the ureter. On the left side, mid- 



158 CYSTOSCOPY AND URETHROSCOPY 

way between the normal and tlie abnormal orifices, there was a short 
canal. The nrinary stream did not traverse this short canal, and as a 
consequence, a stagnation of urine was brought about which resulted 
in the formation of pus in that portion of the canal, which was half 
closed. It was because of this purulent urine that the patient sought 
treatment. 

In the second case (Fig. 102) there AYere two ureters, but they 
were both situated on the patient's right side. On the left side, there 
was no orifice whatever. 

The ureteral orifice may be double ; this is a rare anomaly, but it is 
met. Sometimes there are two ureters for a single kidney, Avhich open 
into the bladder b}" two orifices. Occasionally while one of the two 
ureters opens normally, the other is closed and blind and constitutes 
a little cyst. 

The orifice may be lacking altogether on one side; this is an indica- 
tion that there exists but one kidney. Very rarely an extravesical ter- 
mination of the ureter may also be observed; and lastly, the appear- 
ance of the ureteral orifice may sometimes reveal the exact diagnosis 
without further study. This occurs, for example, when a small stone 
has become impacted in the ureter or when a clot of blood or a parasite 
can be seen at the ureteral orifice. 

REPERElSrCES 

iFenwick: Ureteral Meatoscopy in Obscure Diseases of the Kidney, London, Churchill, 1903; 

also A Handbook of Clinical Electric Light Cystoscopy, London, Churchill, 1904. 
2Garceau : Vesical Appearances in Eenal Suppuration, Boston Med. and Surg. Jour.,' Jan. 

15, 1902. 
3Knorr: Die Cystokopie und Urethroskopie beim Weibe, Berlin, Urban und Schwarzenberg, 

1908. 
■*Pasteau: Trans. Vllle session Ass'n francj.. d'Urologie, 1904, p. 602. 
•'iAIbarran : Ibid., p. 596. 
f'Bazy: Eecueil de Memoires d'Urologie, July, 1911, p. 125. 

Ureteral Ejaculation 

Normall}^, ureteral emission is brought about in the following man- 
ner: The ureteral meatus begins by raising itself with effort, as if un- 
der the influence of a wave, animated by the contraction of the mus- 
cular fibers of the ureter. Next, the orifice opens slightly, giving pas- 
sage to a jet of clear liquid. It remains open an instant and then 
contracts. AVhen this emission is examined carefully, with an indirect 
cystoscope, and a view thus obtained through the water-filled bladder, 
it can be seen that the urine which is emitted from the ureteral orifice 
mixes with the vesical contents like a jet of glycerin would mix with 



I'ltK'i'Kit.M. Aii':A'r()S('oi>v 159 

some water, Al'tcf llic ureteral eiiiissi(»ii, llie orifice of the ui'eter 
closes and i-emaiiis in (•oni|)lete rest imlil 1lie next ejaenlation takes 
place. 

'J'lie emission is oi'dinai'ily icpeale*! every twenty or tiiirty sec- 
onds, l)ut tlie intei'val may l)e lon,ii,er. Wlien tlie emission is studied 
with the direct vision cystoscope held in profile, an actual little .jet of 
water is seen which rises lightly ajjove the oritice like a water spout 
and drops down upon the lateral surface of the oritice. Tliis arrange- 
ment has been drawn after nature and sliown A\ell in Plate X, Fig. 6. 

The ureteral emission may l)e more or less vigorous and accentu- 
ated. It is generally stronger in the case of a single kidney, as seen, 
for example, after nephrectomy. It is also more highly accentuated 
when the orifice is narrower. Indeed, when an examination is made in 
the air-filled hladder, with my direct vision cystoscope, a very fine 
whistling sound may he perceived at the moment of ureteral emission. 
I have been able to make this observation very clearly in a case where 
the lumen of the ureteral meatus Avas found considerably constricted 
as the result of a bloody ulceration of the right ureteral orifice. At the 
moment of emission, a kind of whining sound could be distinctly heard. 

On the other hand, the ureteral emission may be absent. This in- 
dicates either that the corresponding kidney is not functionating or that 
the ureter has become obliterated. This phenomenon is observed dur- 
ing chloroform anesthesia, and it may also be met with in especially 
sensitive persons when a nervous spasm is produced. 

In order to appreciate better the subject of ureteral emission in 
all its details, certain methods have been adopted; among these may be 
mentioned the subcutaneous injection of a sterile solution of methylene 
blue or better still, of indigo carmine. In this manner the ejaculation 
of the ureters can be ol)served with far greater precision. Certain 
authors employ indigo carmine injected a quarter of an hour before 
every cystoscopic examination. In this way, correct information con- 
cerning each ureter can be obtained immediately; and when it is known 
which kidney is affected and to be catheterized, innnediate and exact 
data can thus be secured. This method, recommended by Voelcker and 
Joseph, gives excellent results. It is well to remember, however, that 
it consists essentially in making an intramuscular injection of 4 c.c. of 
a sterile 4 per cent solution of indigo carmine. In fifteen minutes the 
colored ureteral emissions can be seen with the cystoscope. "When the 
kidneys are normal the emission resembles a puff of blue cigarette 
smoke. [When the indigo carmine is injected intravenously, the col- 
ored ejaculation is observed much more quickly. — Editor.] 

Normally, after the injection of indigo carmine, when thi^ kidney 



PLATE IX 

Fig. 1. — Papillomatous tumor of the bladder situated near the left ureteral 
orifice (before treatment). 

Fig. 2. — Apioearance of the same tumor as above, eight days after galvano- 
cauterizatiou. All the villas of the tumor have disappeared ; nothing 
remains but a half burned stump, which readily disapj)eared under a 
second cauterization. When examined a year later, the patient showed 
no trace of recurrence. 




Fig. 1. 




l-iR. 2. 

PLATE IX 



URETERAL MEATOSCOPY 



161 



is ill .i;()()(l work i Hi;' order, llic iirclcinl orifice is easily jukI dearly rec- 
o,i;'iii/('(l. Iii(I('(mI, ilic jcl of si roii^ly coloi-cd iiriiic ciiiaiialing from 
llic urclcra! orilicc may he iilili/cd as a iiscrul ^uide in localiii£!," tlio 
oriliccs. Tliis is os^x-cially valiialtlc for Ix'^iiiiicrs in cystosco])y. It 
sliould always he icinciiilx'riMl llinl wlicii a kidney does nol riinctionate 
l»i<)perly or is entirely lacking, oi' the ureter lias become obliterated, 
the emission of bine urine does not, of course, take place. In these cir- 
(Ministances it would be inipossi))le to establish the diagnosis by the aid 
of iliis iiiciliod alone. 

The ureteral emission may also contain blood. In order to under- 




Fig. 103. — Ejaculation of thick pus, like a whirlpool, from a ureteral orifice (Nitze). 



stand with what precision and clearness the diagnosis of renal hema- 
t iii-ia may be made, it is necessary to ol^serve a bloody ejaculation from 
a ureteral orifice in the midst of a clear bladder lluid, scattering itself 
like the smoke of a cigarette in the air. A\nien the reiuil hematuria is 
marked, the condition may be compared with a factory chinmey emit- 
ting smoke interiuittently. Occasionally in addition to fresh blood, 
elongated worm-shaped blood clots luay be seen emerging from the 
ureters. In these cases we should think of the i)ossible existence of a 
renal neoplasm. 

The ureteral emission may also contain pus; and it is always in- 
teresting whenever x>(>^!^ibh' to note the manner in which the pus 



162 CYSTOSCOPY AXD rRETHROSCOPY 

emerges from tlie ureteral orifice. When, instead of liaving a real 
pnrnlent emission like a whirlpool (Fig. 103) the pus dribbles out at 
long intervals like a drop of vaseline or as if coming out of a ^ollapsi- 
)3le j)aint tube (Fig. 101), it may he concluded that the corresponding- 
kidney is functionating very badly. 




Fig. 104. — Ejaculation of pus from a ureteral orifice as from a tube of paint (Nitze). 

Location of the Ureteral Orifices 

The location of the ureteral orifices often has to be noted care- 
fulh^ when surgical intervention is rec{uired in the bladder. "When, 
for example, there is a bladder tumor which is near the ureter, it is well 
to know the exact relations that this tumor bears with the ureteral 
orifice before undertaking surgical measures. 

ERRORS IN CYSTOSCOPY 

Though cystoscopy is a marvelous method of examination which 
it is impossible and even rash to ignore, it is, nevertheless, true as we 
Jiave already stated, that the essential condition making for its use- 
fulness is the projDer interpretation of the pictures which it furnishes. 
The interpretation is of prime importance and this can not be accpiired 
except by a large exjDerience and considerable practice. There is no 



(loill 


)1 tli.-il cri'ors may he made 


all t 


lie dinicilllics ol' 1 his iiicHkx 


Willi 


('ys1()S('<)|)y. 



Ki;i:(»i;s ly cvstoscopv K!.'' 

hy lH'i;iiiii('rs wlio Ii.mnc iioI onci'coihc 
cNcii llioiiuli llicy <'iij()_\' a I'amiliai'il \' 

( )ii(' of llic errors thai iiia_\' he iiia(h' is lo iiiisla!-;(' an cxI I'ax'csical 
liiiiior which ch'N'atcs Ihc x'csical mucosa For a liimor of ihc 
hhuhlci' pfopci'. '^Plic most siiiiph' case, as well as Ihc most rrc(jiicii1, is 
Ihal whicli is observed duriiijj,' ])re^'iiaii('y, when the hladtU'i- is i-aised 
hy tlie ,i;-rnvid uterus. In tlie same way the l)ullous edema wliich is 
ol'teii met with in tlie rundus of the reniale hhuhlei' is soiiictiiiies diK' 
solely to the existence of a uterine cancer. 

A second error wlncli uuiy be made is tliat of niistakiuL;- a clironic 
cystitis for a vesical tumor. Sometimes the cystitis takes on sucli ]jro- 
])ortions tlud it com})letely deforms tlie vesical mucosa. The lattei- oc- 
casionally i)resents real vegetations wddch simulate a real tumoi- of 
the bladder. The imj^ortant point in the diagnosis is that the lesions 
are nnu-h more limited and circumscribed in the case of vesica! tu- 
mors, while, on the contrary, they are in most instances diffuse and 
multiple in cystitis. Nevertheless, in certain cases one may be in doubt 
as to the correct diagnosis. I have found myself in similar circum- 
stances, and the only method that has enabled me to establish a diag- 
nosis was through biopsy. The reader is referred to the chapter on 
Vesical Biopsy for fiu'ther details. 

The differential diagnosis between a vesical tumor aiul a blood 
clot is sometimes very embarrassing. The best procedure consists in 
trying to move the mass by means of the cystoscope itself. The clot 
is mobile, it may possibly l)e broken up and does not bleed. The tumor 
on the other hand, does not j^ossess these characteristics, hut it has 
this special feature; namely, that it bleeds easily on the slightest con- 
tact. 

Cystoscopic differential diagnosis between a benign tumor (iiajul- 
loma) and a nu"ilignant tumor (cancer) is often very delicate, and as in 
the preceding instance, can not be decided at times except through bi- 
opsy; however, it is possible by a simple cystoscopic examination in 
the average case to establish (h^finitely betAveen a benign and a uialig- 
naid tumor. 

Papillonui is more fre(|ueid than cancer and ai)]tears usually in tlie 
form of a fringed tunu)r, lloating, rose-colored and of a velvety ras])- 
ben-ydike appearance. It is especiallv characterized by tln^ lightness 
of its outline. Vesical papillomata haxc long, tine, slendei', and thin 
])i-olongations which extend I'ai- fiom the sui-facc of ini])lanta1i()U. 

Cancer, to the conti-ary, is most often largei- in size, with a more 
extensive imjilantation. Its ap])earance is rough; its base usually seems 



164 CYSTOSCOPY AND URETHROSCOPY 

much more fixed and more solid. Finally, in the vast majority of cases, 
the cancerous tumor presents eschars of blackish or grayish color. This 
opaque and dark coloring is not met with usually in benign tumors. 

Calculus and tumor do not often present great difficulties in their 
differential diagnosis, except, however, in those cases in which the tu- 
mor is necrotic and encrusted with phosphates. Weitz reports a case 
of tumor encrusted with phosphates in which the error in diagnosis was 
possible even with the naked eye. Like a case reported by Dittel, this 
proved to be a tumor, which was removed by excision. 

In the average case, a calculus is easily recognized by its mobil- 
ity when touched with the cystoscope; a calculus never pulsates or 
beats like some tumors in the bladder; and lastly, when a calculus is 
touched with the cystoscope or a metallic searcher a typical resonance 
is heard as a result of the contact. 

The diagnosis between a calculus and an accumulation of pus does 
not present any difficulty. However, I have had occasion to observe a 
pertinent case. The patient was suffering from retention of urine of 
medullary origin and was obliged to catheterize himself. Cystoscopy 
showed a large white mass in the fundus of the bladder which gave the 
impression of being a calculus, at first sight ; but on touching it with the 
cystoscope, there was no sensation of contact with a hard substance 
and the whitish mass was easily broken up. Finally, a copious irriga- 
tion of the bladder brought forth large purulent masses, thus definitely 
determining the absence of a calculus. 

Another error is that which mistakes a diverticulum of the bladder 
produced by the crossing of two vesical trabeculse for a ureteral 
orifice. In this case the ureteral catheter makes the diagnosis by 
striking the vesical mucosa at the base of the diverticulum. HoAvever, 
when the ureteral meatus is very small and narrow (atresia), it is 
often quite difficult to say whether we are dealing with a strictured 
ureteral meatus or with a shallow diverticulum. 

The diagnosis between an orifice of the ureter and a deep ulcer- 
ation due to cystitis is often a delicate one. In cystitis, fissures or 
rhagades of the vesical mucosa are sometimes produced and between 
the lips of these fissures are seen more or less bloody orifices which 
might be mistaken for an inflamed ureteral orifice. 

An error in diagnosis may result in the differentiation between a 
ureterocele or a cyst of the lower end of the ureter and a tumor of the 
bladder. An instance of this kind which has been observed is reported 
further on (see page 235). The same may be said as to the differential 
diagnosis between a varix of the bladder neck and a vegetating tumor 
at the neck. The point to remember is that bladder tumors at the neck 



dan(;ki;s oi' cystoscopy 165 

apjx'ar most oricii in tlic U)V\\\ ol' a ,l!,I()\"(' (iii,L;'<'i', i-atlicr loni;- and thick, 
wlicrcnis llic vai-ic('S arc usually attacliccl to tlic l)la(l<l<'i- nuicosa and 
arc immobile. 

Tlic diagnosis hotwoon a bladdoi- tumor and an onlaT-,£j:od median 
]()l)c of tlic ])rostatc is sometimes i-atlicr diffieult, espeeially as these 
prostatic lobes are frequently pcdicuhiliMl, thus makiu.i;- the diagnosis 
(|iiite complex. 

Bearino- in mind all the difficulties in diagnosis which have just 
hccii enumerated, it is essential to take every possible precaution 
against error; among these, the most important is to be familial- willi 
all methods of examination and not to limit oneself to a single instru- 
ment or to a single method. We shall see in the following chapter that 
both indirect (prismatic) and direct vision cystoscopy should be of 
nmtual assistance, and when one is found wanting, Ave must turn to the 
other. A combination of both of these methods assures a mathemati- 
cally exact and absolutely perfect diagnosis. 

DANGERS OF CYSTOSCOPY 

A^Hien cystoscopy is practiced according to the rules which are de- 
scribed further on (pages 182 and 229) it is absolutely without any 
danger, and when carried out under favorable conditions, it is as easy 
as simple catheterization of the bladder. Nevertheless all the precau- 
tions that have been indicated should be taken, even to the minutest 
degree. The first of these precautions and the most important, in point 
of fact, is a most thorough asepsis. If this is neglected, complications 
ma}^ result, among which are the following : 

1. Infection. — The cystoscope may become the source of a vesical 
infection exactly as any sound that is not aseptic when introduced. 
This infection makes itself apparent by the usual sAuuptomatic triad, 
Avhich is observed in cystitis, — pyuria, pollakiuria, and pain after 
urination. 

2. Bums of the Vesical Mucosa. — Formerly when warm lamps 
were used, it frequently happened that little burns were produced when 
the lamps remained long enough in contact Avith a given point of the 
vesical mucosa; these burns appeared in the form of round spots re- 
sembling a more or less pronounced scar. I had the opportunity of 
observing similar burns some years ago, Avhich had resulted from a 
cystoscopic examination which had been made some days previously 
by a colleague, with a lamp that was too hot. But today Avhen the 
so-called cold lamps are employed universally, tliesc^ accidents can not 
occur. 



166 



CYSTOSCOPY AND URETHROSCOPY 



3. Constitutional Symptoms. — In performing cystoscopy in a case 
of severe cystitis, it is quite certain that complications may he induced, 
such as a rise in temperature and a severe constitutional I'^action. 
Care should he taken to prevent the development of these complications. 

4. Electrical Disturbances. — These constitute a rather disagree- 
able complication Avhich I have observed twice, and which I could not 
at first explain. It sometimes happens that the cystoscope having been 
introduced properly, and the conducting wire or cable applied, the 
patient suffers a very painful electric shock as soon as the current is 
turned on, thus rendering the examination impossible. After many 
investigations, every possible fault of the instrument having been 




105. — Bladder phantom. 



eliminated, I have been able to note that this happened only in cases 
in which the patient 's prepuce Avas so long that it came in contact with 
the arms of the electric conducting rod, and that in these circumstances 
a short circuit was produced, 

[In the editor's experience, this phenomenon has occurred even 
in patients who had no foreskins that might come in contact with the 
connecting wire. It has been observed that a moist cement or wooden 
tioor acts as conductor of the current, and if the patient places his 
hands on the sides of the iron table, he thus completes the circuit and 
produces the shock. This can be avoided by placing a thick rubber mat- 
ting or sheeting under the legs of the table, thus insulating it; the 
operator's stool should also be similarlv insulated. It goes Avithout 



DAXCIOIIS OK ('VST()S('()|'\- 1 ()7 

s.-iyiiii;' llial llic |)ali<'iil shall likewise lie dii a nil)l)i'r sheet spread over 
I he table. — i^DITOIt. I 

The daiigcis that iiia\ Tolhiw cat heteri/atioii of the iirctors, sucli 
as iiir(>('tioii and perl'oi'at ieii, are diseiis^^ed lurther en (sec pa.n'c 2f)';). 

Vesical Phantoms.- In order lo learn c\>-1oscopy, hc.uiiiiici-s will 
often lind it to their adwanta^c lo use phanloins which nix'c a picture 
similar to that of the iiitorior ol' the bladder. These phantoms are 
iisuall>' made of laihher, and their iiiterioi- is paintetl to represent the 
base of the bladder with tlie uretei'al orifices and the intern rderal li.i^'a- 
nieiit. Numerous moch'ls may be had, the most practical beinii,- those 
that a])proaeli i-eality as nearly as possible, '^j'liese are jilled with water 
and provi(h'd witli sy])lions tliat end at tlie ima,uiuai->' ureteral oi-ifices. 
The hitter are snrmonnted with two 1)otth'S wliicli re])i'eseut the ni-eters 
and kidneys. The most commonly nsed phantoms are tlie moch'ls made- 
by Janet, Frank, Eitze, Viertel, and AVossidlo. 

An economic way to secnre a phantom is to make one: Take a 
connnon rnh])er halloon or football of small size, the ordinai-y cl:ild's 
toy. Make a central anterior opening' to represent the nrethra, throngii 
Avhich the urethroscope is introduced; make tw^o little side openings, 
placed symmetrically, to represent the ureteral orifices. This balloon 
is attached to a little hoard, and thus provides means of exercise at 
small expense, in the hei^'innino-s of cystoscopy. By cutting' this halloon 
lioiizontally in its greatest diameter, the desired linage may he drawn 
or painted in its lower segment and. thus studied through the cystoscope. 
The beginner thus learns how to int(n"pret cystoscopic pictures, this be- 
ing the greatest difficulty in the practice of cystoscopy. This practice 
is especially useful in prismatic cystoscopy for the images are con- 
siderably displaced and deformed, varying according to the distance 
at Avhich the prism is held, and so forth. With these vesical phantoms 
the l)eginner wall acquire a certain degr(H' of experience and digital skill 
which is so essential in the practice of cystoscopy in the living subject. 



CHAPTEK V 
PEISMATIC (INDIRECT) CYSTOSCOPY 

The indirect vision cystoscope is essentially an instrument for 
vesical exploration. At the present day, its nse is general for the 
examination of the walls of the bladder, and its indications are many 
and varied. 

Nitze's Prismatic Cystoscope. — The prismatic cystoscope of Nitze 
and those Avhich are derived from it are today the instruments most 
connnonly nsed in the examination of the vesical cavity. Nitze's 
instrmnent consists of a metallic catlieter with one extremity bent 
like a crutch (Fig. 106). Its caliber corresponds to No. 21 Charriere, 
and its length is 20 centimeters. The crutch-lilve extremity bears a 
little electric lamp designed to light up the parts corresponding to 
the concavity of the instrument. These lamps are highly i^erfected 
and are perfectly cold when lighted, at least when new. 

Of the two wires that bring the current to the lamp, one is insulated 
in its entire length in the wall of the instrument; the other is con- 
nected Avith the metallic wall itself. The current is brought to the in- 
strument by means of a pair of arms in the form of a double fork which 
is apx)lied by simple contact to two rings attached to the neck of the 
cystoscope. Because of this arrangement the cystoscope may be turned 
in all directions Avithout interrupting the electric current. The eye- 
piece of the cystoscoiDe presents a little immovable button Avhich con- 
stantly informs the observer as to the exact position of the prism. 

The body of the cystoscope is straight and its extremity is bent, 
as already stated, like a crutch. At the elbow thus formed, is a reflect- 
ing prism, upon which are reflected the images of those portions of the 
bladder which are illuminated by the electric lamp. In the body or 
shaft is a series of lenses which magnify the image ; these lenses make 
up the optical system of Nitze. 

. Nitze's Optical System. — This consists of three sets of lenses. At 
the vesical extremity is a compound lens generally called the "objec- 
tive." This furnishes a real, inverted image. As this image is very 
small, being formed at a close distance and backward, it would be im- 
possible to see it with the naked eye. That is why a second lens is 
XDlaced behind it near the middle of the shaft or body of the cystoscope ; 



PKISMATIC (iXKUIKCT) CYSTOSCOPY 169 

tlio iiuai^'c is thus hroii.^lil t'rom the vesical cxti'diiity of llic tiihc to 
its cxtorior cxt rciiiil y (|iiil(' close to llic so-cnlIc(l "ociilai'." Tlic latter 
acts only as a strong- iiia,i;iii Tying glass, that is to say, it enlarges the 
(lir(!ct image already obtained. 

To recapitulate: Three lenses constitute tlie optical system (jT 




^ 



Fig. 106. — Nitze's cystoscope. 

Nitze; one situated at the vesical extremity, the '' objective;" the sec- 
ond situated at the middle of the body or shaft, and the third is the 
' ' ocular. ' ' 

To this optical system is added a rectangular prism, which is 
placed in front of tlie objective. This prism is arranged so that one of 




Fig. 107. — Sectional view of Nitze's cystoscope (Nitze). a, metallic capsule which holds the lamp; 
b, contact wire of the lamp terminating in a fine spiral; c, metallic part into which the lamp is screwed; 
d, fine insulated platinum plate, which makes the contact with the spiral wire, h ; e, lens. 

its surfaces is perpendicular to and the other parallel with the longi- 
tudinal axis of the instrument, with which the hypothenuse of the rec- 
tangular prism must form an angle of 45 degrees. The hypothenuse 
presents a mirror which sends back the luminous rays that enter 
through the lateral window of the instrument. 



A' 




Fig. 108. — Optical system of Nitze's cystoscope. 



The effect of this prism is to displace the visual })laiu> to the extent 
of 90 degrees. It is because of this pi-ism that the images obtained 
present varied irregularities, alterations and displacements Avhich do 
not give an entirely exact idea of the real appearance of the objects 



170 



CYSTOSCOPY AXD rRETflEOSCOPY 



examined. All objects placed vertically are seen in the horizontal 
plane, and on the other hand, what is really horizontal becomes vertical. 
Moreover what is in front is seen behind, in the cystoscopic pictnre, and 
objects that are located superiorly are seen inferiorly, and reciprocally, 
in the \^sual field. On the other hand, objects situated on the right or 
left side are seen on the corresponding side. 

In addition to the optical system and the prism, the cystoscope 
presents a lamp i)laced in front of the prism at the ''beak," which is 
joined to the shaft or tube at an obtuse angle based on the so-called 
"Mercier's crutch curve." At the ocular end of the cystoscope are 
two metallic rings isolated one from the other, one of which is soldered 
to the metal of the instrument itself. The other is attached to the 
conducting wire which penetrates into the interior of the shaft by a 
special groove. 

The Cystoscopic Lamp. — The lamp is situated at the beak, and 




Fig. 109. — Cystoscope lamp and its mounting. 

hooded in a metallic cap. Its free extremity constitutes the beak of the 
instrument, while the other end presents a screw by means of which 
the lamp is attached to the shaft of the instrument. One of the x3oles 
which serve to bring the current to the lamp is directly in contact ^^^th 
the metallic hood which partially covers the lamp. The other is rolled 
up in a fine spiral and brought into contact with the interior conducting 
^^ire which is placed in the shaft of the instrument and which it follows 
in its entire length. At this point the current frequently fails because 
of poor contact, and it is well to remember that the condition of this 
little spiral must be investigated when a lamp will not Inirn. By 
lengthening this spiral with a pair of forceps, a better contact is ob- 
tained. The greatest gentleness must be emplo3'ed, for the spiral is 
extremely fragile and breaks easily. 

The filaments of the lamp were formerly made of carbon, but they 
had the disadvantage of generating a great deal of heat. At the 



PIMS.MATIC (iXDIIM-X'T) C'VSTDSCOPV 



171 



l)r<'sciit lime, willi tlic use of nictallic rilaiiicnts a iiiitcli more iiilciiso 
illmiiiiia1i(»ii is (»l)taiiic(l and the hinips ai-c aliiiosi always cold; tlicy 
hccoiiic warm only alter ])r()l()iii;<'(l use {F'l'j;. 109). 

Rotating Contact.- -Tlie current is cai-riod into the iiiU'iioi- ol" tlie 
cystosc()])c l)\ iiicaiis ol" a special rotatin.i;- contact (pincers) in the 
sliape of a fork with two l)ranches separated one froni tlic otlier (Vvj;. 
110). These branches ai-c connected Avitli the contact riii^-s of the 
cystoscopy In the center ol' the lork is a small slide hv means of which 





Fig. 110. — Ordinary attachment of the indirect 
cystoscope. 



Fig. 111. — E. Frank's improved attachment for 
the indirect cystoscope. 



the current may ])e turned on or ofC at will. This rotatin.u- contact 
works very well when in good condition, l)ut if not inoperly cared foi', 
i. e., permitted to get dirty or rusty, a poor contact results. 

Frank, of B<'rlin, has moditied this pair ol' pincers in the following 
maimer: Instead of having it end in a douhle foi-k. the ])arts move in a 
semicircle Avhich is narrowed or widened liy the aid of a flat ivory bolt 
so that it can seize the cystoscope firmly, yet allowing the latter to turn 



172 



CYSTOSCOPY AND URETHROSCOPY 



easily in its grip. Variations and interruptions Avhieli are so annoying 
during an examination are avoided Avitli this instrument (Fig. 111). 
Such was the original cystoscope of Nitze, the appearance of which 
soon afterward gave rise to many improvements. Disregarding for the 
moment those changes which aimed at perfecting ureteral catheteriza- 
tion, or the treatment of vesical tumors or of foreign bodies in the 
bladder, we shall consider in this chapter only those improvements 
which gave a better view of the vesical walls, A full consideration of 
these many improvements would occupy many chapters, but we shall 
study them briefly: 

1. Modifications for obtaining a direct view of objects. 

2. Modifications for magnification of images and enlargement of 
the visual field. 

3. Modifications for irrigating the bladder. 

4. Modification for securing a view of the bladder neck. 

5. Modification for securing binocular vision. 

AB 








i;^ 






t 



Fig. 112. — Course of the light rays in the Nitze-Frank cystoscope. 



6. Modification for securing rectification of cystoscopic images. 

7. Modification for endovesical ]Dhotograi3hy. 

8. Modification for ureteral catheterization. 

9. Modification for endovesical operations. 

10. The pancystoscope of Baer. 

1. Modifications for Obtaining a Direct View of Objects. — Tlie first 
experiments made with the object of correcting the deformities pro- 
duced by the cystoscope, were made by Weinberg, in 1906, and by 
Frank, in 1907. In 1906 the former devised liis "orthokystoscop," in 
which the correcting lens was placed, not in the shaft of the instrument, 
but in a separate mounting affixed to the ocular. But this instrument 
only permitted the examination of a part of the base of the bladder 
and of the nearest portion of its circumference. 

Ernest Frank's cystoscope which appeared in 1907^ is character- 
ized essentially by the presence in the optical apparatus of a second 



PRisMATrc (indirect) cystoscopy 



173 



prism, wliicli coitccIs llic iin'ci'lcMl iin;i,i;(' in ilic lii'st pi'isiii (Fift'S. 118 
and 114). Tliis corrective optical syslcin may he adapted to all cyslo- 
scopes ill tlie fonii of a movable moiiiiliii.i;- a(laj)l('(l to ilic ocular so lliat 




Fig. 113. — Cystoscopic image in the early cystoscopes (inverted). 

neither the outer appearance of the instrument nor the customary 
manner of use need be modified in the least degree. With this cysto- 




Fig. 114. — Cystoscopic image corrected in Frank's new cystoscope. Double catheterization of the ureters. 

scope the real appearance of the entire bladder can be studied without 
inversion of the image, and besides, the illumination is very bright. 
2. Modifications for Magnifying the Image. — In 1909, Otto Ring- 




Fig. 115. — Course of the light rays in a cystoscope, witli Ringleb's system. 

1(^1), of Berlin, devised a special optical systcMii constructed on tlie ty])(' 
of the telescope (Fig. 115); this instrument should i)ropeiiy be raugiMl 
with microscopes of the immersion type and with slight magnihcation. 



174 CYSTOSCOPY AND UEETHEOSCOPY 

This oiDtical system corrects tlie inverted image and obtains this result 
by means of two corrective arrangements combined with a prism in the 
form of Amici's "roof" or "garret" (Fig. 116). Throngh'^this ar- 
rangement, erect and true pictures are obtained. Ringieb's cystoscope 
has a large visual field and joroduces cystoscopic j)ictures of great 
clarity. Unfortunately this instrument, which is very exj^ensive, finds 
its greatest utility when it is desired to make a minute examination of 
the details of a given point in the bladder. Quoting Hogge, 
^^^ of Liege, "as compared with the analogous instrument of 

^V^k Nitze, the visual field is smaller, but what is seen, is seen 
^^^ admirabh'. " 
^H The cystoscope of AVilliam Otis, of New York, was de- 

^ vised in order to olitain a large visual field. In this in- 
X strument the prism is replaced by a hemispherical lens the 
___/ flat surface of Avhich is silvered. The substitution of this 

Fig. 116.— bomispherical lens is ecpiivalent to the addition of two 

Amici's prism, f>Ti ii • -\ 

in the form plauocouvex leuses ; ot the latter, the lens occupvmg the 

of a housetop. . „ . x . ■ 

upper portion of the prism assembles the rays at a large 
angle and brings them together on the hypothenuse ; the other on the 
anterior surface of the prism, corresponds to the first lens in the tele- 
scope. Otis obtained a visual field four times greater than that ob- 
tained with any other rectangular cystoscope ; in addition, the picture 
is also very clear. 

3. Modifications for Bladder Irrig-ation. — It being absolutely nec- 
essary that the bladder contents shall be perfectly transparent in or- 
der to practice cystoscopy, and since the presence of pus or blood'may 




Fig. 117. — Brenner's cystoscope. 



cloud the bladder fluid, many efforts have been made to remedy this 
inconvenience. Many authors have devised instruments with the ob- 
ject of permitting bladder irrigation during the cystoscoiDic exam- 
ination. 

BRE:N'iSrER/'s Cystoscope. — Brenner's Avas the first cystoscope (Fig. 
117) in which the visual field and the lamp were situated on the convex- 



PniS.MATlC ( I xdiiikct) cvstoscopv 175 

iiy of llic hcak. I'liis insl rniiiciil was |)r()\i(l(Ml willi a small lulx' on its 
convex side fof llic ii'ii,i;ali()ii of llic hiaddcr diirin.^- Ilic <'ystosfo])i(' 
cxaiiiiiialioii. lii addition, this canal alliiou,a,li oL' line calilxM' was in- 
tended to afford facility for tiie passa^'e of a ureteral catlietei". 

Mkcai.oscopk ov Botsseau dit Rocher. — Tills author- devised a cyst- 
()sc()])(' wirn-li lie called a '•nieij,-aloscoi)e," It was conipose(l of two se])- 
arate parts. One consisted of a hollow catheter of No. 23 Charriere cal- 
iber, elltowed near its extremity and provided at this point with a very 
small electric lamp; the second, or optical portion, which slipped into 
and ])enetrated the first, comj^rised a tul)e wliicli contained lenses and 
a i3rism. The latter was arranged in such a manner tliat it fitted into 
a window prepared for this purpose, in the hollow catheter just men- 
tioned. AVhen the first portion was introduced into the bladder, with- 
out the optical portion, vesical irrigation was possil)le as with an or- 
dinary catheter. Later, Boisseau du Tvoclier''' added two little irrigation 
tul)es to the convex portion of his instrument Avhich serve to irrigate 
the bladder during the examination and also facilitate the passage of 
ureteral catheters. 

Guterbeock's Cystoscope. — This author's* instrument strongly re- 
sembles the megaloscope of Boisseau du Rocher. As in the preceding, 
the catheter and the optical apparatus are independent of each other, 
which facilitates bladder irrigation during the examination when the 
optical portion is removed. The catheter, slightly elbowed at its ves- 
ical extremity, was pierced by two orifices tlirough Avhich the bladder 
was irrigated. In the interior of this catheter a tube bearing the lamf), 
the prism, and the optical system, was inserted. The lamp and the 
prism were thus placed exactly at the opening in the catheter. 

Fexwick's Cystoscope. — This instrument, based on the same prin- 
ciple as Guterbrock's, is an improvement on the latter. It is likewise 
composed of two distinct parts. The holloAv sound differs from the pre- 
ceding instrument' in that it bears only one large oriiice (instead of 
two), thus iDermitting l)la(lder irrigation. During the examination, the 
lamp and prism are brought to this point and maintained there. The 
cystoscope of Kollmami, of Leipzig, is also constructed according to 
these principles. 

All of these instruments come under the category of irrigating 
cystoscopes, of which every urologist ought to possess at least one 
model, for they are indispensal)le in very many circumstances. They 
may be referred to a model type which consists of a hollow sound, el- 
l)()wed in the form of a crutch, Avith an oi)ening near the elbow through 
which water iiiav he inti-oduced into the ])la(l(ler and withdrawn at will. 



PLATE X 

Fig. 1. — Normal appearance of the bladder neck as seen with the direct 
vision cystoscope. The first ling represents the end of the urethra; 
the dark central portion represents the darkened base of the bladder. 

Fig. 2. — Cicatrix of a vesical perforation due to the rupture of an abscess 
in the vicinity of the bladder. 

Fig. 3. — Large papillomatous tumors of the bladder neck. 

Fig. 4. — Application of the galvavocaatcry to the tumor at the lower part 
of the bladder neck (compare this with Fig. 3). 

Fig. 5. — Appearance of a normal ureteral orifice. 

Fig. 6. — Normal emission of the right ureter as seen with the direct vision 
cystoscope. In this case, the cystoscoj^ic tube is held in profile, and not 
in full view. The urine is thus observed leaving the ureter in the form 
of a little jet of water. 




-9% 



Fig. 1. 



Fig. 2. 





Fig. 3. 



Fig. 4. 




Fig. 5. 



Fig. 6. 



PLATE X 



PRISMATIC (indirect) CYSTOSCOPY 177 

Jn llic iiilci'ioi- of lliis liollow sound an oLlui-nloi- is inserted, carrying 
a ])risiu and optical system, in oi-dci- lliat the optical obturator (tel- 
escojje) may be introduced while tlie l)ladder is full of water, a bolt 
with an automatic valve is provided (Fig. 118). 

Ti-rio-ating cystoscopes often render the greatest service, particu- 
larly in the examination of a tumor of the bladder which bleeds freely; 
the liemoi-rhage thus produced in these cases would otherwise make a 
clear view impossible. The technic employed with the irrigating cysto- 
scoj^e is as follows: The bladder is cleansed through an ordinary cath- 
eter, with Avarm boric solution. The cystoscope is introduced and an 
effort is made to see clearly. If the vesical region is found obscured 
by the presence of pus or blood, the optical piece in the interior of the 
tube is Avithdrawn and a little rubber joint mounted on a metallic piece 
is inserted in its place, which permits temporary occlusion of this tube. 
The unclean fluid is alloAved to run out and clear fluid is injected to re- 




Fig. 118. — Automatic valve, in irrigating cystoscopes, which can be opened for the insertion of the 
optical part, and when this is withdrawn, it closes automatically, thus preventing the escape of the bladder 
fluid. 

place it. The metallic piece is now removed, the optical system (tele- 
scope) is reintroduced and the examination is continued. 

This arrangement has notable advantages, especially A\dien we are 
dealing with prostatic lesions or with a congested prostate which bleeds 
on contact Avitli the instrument. Furthermore, once the prostate has 
been jDassed, there is no further bleeding after the instrument has en- 
tered the bladder.. Unfortunately, in spite of these really important im- 
])rovements, it is, nevertheless, true tliat in a great many cases renal 
or vesical bleeding prevents a clear view with the prismatic cystoscope ; 
in these instances, direct vision cystoscopy must be resorted to. 
4. Improvements for Viewing the Bladder Neck. — 
Nitze's Vesical Cy.stoscope Xo. 3. — In order to olitain a view of 
the vesical neck, Nitze devised a special model Avitli a modified elbow 
wliidi lie called ''cystoscope No. 3;" with this instrument the vesical 
neck could be seen easily. 

ScHLACiiNTWEix's Cystoscope. — 'I'his autlior' later solved the diffi- 
cult problem of obtaining a direct vicnv of the bladder neck by adopt- 



178 



CYSTOSCOPY AISTD l^EETHEOSCOPY 



ing a movable prism controlled from witliont (Fig. 119). By means of 
a special mechanism the prism can be projected forward and thus a 
retrograde view of the bladder neck can be obtained. Throngli" a very 
simple maneuver the prism is made to return to its original position. 
Thus this instrument may serve not alone for the inspection of the 




Fig. J 19. — Schlagintweit's cystoscope. 



vesical neck, but also for the examination of the entire bladder like a 
cystoscope with the ordinary prism. 

5. Improvements for Securing Binocular Vision. — In order to ob- 
tain a view of an ol^jcct situated in the bladder with l)oth eyes and thus 




Fig. 121. — Sectional view of Kutner's cystoscope. 



secure the relief furnished by binocular vision, Jacoby,*" of Berlin, de- 
vised a stereocystoscope through which the bladder can be seen with 
both eyes. This method of examination greatly facilitates the proper 
interpretation of the images, especially for beginners. 



PRISMATIC ( INDIRECT ) CYSTOSCOPY 



179 



Kutner's ])EMO]srsTRATioi>r Apparatus. — In order to pormit two ob- 
servers to examine the bladder simultaneously, Kutner devised an ap- 
paratus which may be adapted to the eystoseope (Figs. 120 and 121). 
This apparatus consists of a bifurcated tube which is attached to the 
ocular of the eystoseope. At the point of intersection of the axis of the 
long' and short tubes, a little trans])arent mirror is inclined at an 
angle of 30 degrees with the axis of the tube. The mirror divides the 
luminous rays into two parts. One portion traverses the mirror and 
finally strikes the optical apparatus of the short tube; the other is 
reflected by the mirror into the long tube. The images seen by both 
observers are comparatively clear and clean-cut. 

6. Modifications for Rectification of the Image. — 
Jacoby's Corrective Mounting. — During the cystoscopic examina- 
tion, the images perceived are invariably considerably displaced as 




Fig. 122. — Jacoby's corrective mounting. 



compared with the real position of the objects themselves. In order to 
obviate this condition, Jacob}^ devised a corrective apparatus (Fig. 
122) by means of which the real position of the objects in the cysto- 
scopic picture can be determined. Tliis api^aratus is attached by means 
of a screw in front of the ocular of the cystoscopes ordinarily used. It 
consists of a rotary prism which is easily turned, a vertical dial which 
oscillates on a circular disc divided into degrees and another situated 
behind the dial and provided with a button. By rotating the corrective 
prism the exact situation of objects is easily found with this axjparatus. 
7. Modifications for Endovesical Photography. — The beautiful pic- 
tures seen with the eystoseope long ago inspired attempts at j)hotog- 
raphy for permanent record. The first photographic attemiDts made 



180 



CYSTOSCOPY AND URETHROSCOPY 



by Antal, at Budapest, and by Kntner, were not satisfactory, Mtze^ 
perfected the method and obtained highly satisfactory results. Im- 
portant improvements were subsequently made by Hirschmaifn, and 
later by Berger.^ One of the most practical methods of photography is 
that of Kollmann, of Leipzig (Fig. 123). Jacoby, of Berlin, subse- 
quently perfected a stereocystograph, with which stereoscopic images 
of objects situated in the bladder can be obtained. 

8. Modifications for Ureteral Catheterization. — The modifications 
having this object in view are fully described in a later chapter. 

9. Modifications for Endovesical Operations. — These changes are 
also described later (See Treatment of Bladder Tumors). 

10. Baer's Pancystoscope. — Baer, of A¥iesbaden, comprised the 
principal modern improvements contributed to cystoscopy in one in- 
strument which he named the ''universal instrument" or "pancysto- 
scope." It consists of a tube in which the movable optical portion of 
the various cystoscopes is inserted. With this instrument it is a simple 




Fig. 123. — Kollmann's photographic cystoscope. 



matter to substitute one optical system for another or to introduce into 
the tube a series of instruments, such as catheters for the bladder and 
ureters, galvanocautery handles, forceps, curettes, etc. 

This instrument has very distinct advantages, for it makes possible 
the use of ureteral catheters of rather large caliber, No. 9, Charriere, 
for example. It also enjoys all the advantages of the irrigating cysto- 
scope. Lastly it makes endovesical operations possible. Unfortu- 
nately, it is really not very practical, because it is too complicated and 
deteriorates easily. 

REFEREI^CES 

iFiank: Trans. Assn. franq,. d 'Urologie, 1907, p. 452. 

-Boisseau du Eocher: Ann. d. Mai. d. org. genito-uiin., 1890; De 1 'endoscopic a lumiere ex- 

terne et de I'endoscopie a lumiere interne, Ibid., 1892, p. 413; Ibid., 1894, p. 51. 
-Boisseau du Rocher: Cystoscopie et catheterisme des ureteres, Ann. d. mal. d. org. genito- 

urin., 1898. 
iGuterbrock: Berl. klin. Wchnschr., 1895, No. 29, p. 628. 



TECHNIC OF INDIRECT VISIOIsr CYSTOSCOPY 



181 



!"'S('lil;i^iiil w(^i( : Dus rctifi^riKic Kystnskop, fciif r;illil. I', d. Kiaiikli. d. Ifjirii u. Scx.-Or^., 

190;;, xiv, 1). 202. 
•iJacoby: Lc Stcroocystoscopc, Ann. gonito-urin., March 1, 1906, p. 359. 
7Nitze: Kystophotosi'aphisclu'r Atlas, Wiosbaclcn, 1894. 
«Bcrgcr: Notice sur la photograxiliic dc la vessic, Ann. gcnito-uriii., 1900, p. 414. 



TECHNIC OF INDIRECT VISION (PRISMATIC) 
CYSTOSCOPY 

Sterilization of the Cystoscope. — Tlio prismatic cystoscope sliould 
l)e sterilized in a formalin sterilizer, of which I have described^ one of 
the most simple and practical types (Fig. 124). Tliis apparatus con- 
sists of a simple tul)e of large caliber, open at both ends, and carrying 
at each end a metallic furrow, upon which is screwed a perforated 




Fig. 124. — Formaldehyde sterilizer. 

metallic stopper provided with a ferule. At one extremity a rubber 
tube is fastened, which connects the glass tube to a bottle filled with 
])ure formol; at the other extremity is a rubber tube in direct con- 
nection Avith a water spigot. 

This apparatus is extremely simple. By opening the water tap, 
a vacuum is created in the sterilizing tube whicli takes up the air that 
comes bubbling up into the formol and becomes charged with formalde- 
hyde vapor. This vapor, constantly fresh and continually renewed, 
completely sterilizes the instruments contained in the interior of the 
tube in fifteen minutes. 

The great advantage of this principle of sterilization, which was 
devised by Suarez de Mendoza, of IMadrid," is that in addition to its 



182 CYSTOSCOPY A]<rD URETHROSCOPY 

complete secimty from the point of view of disinfection, it is abso- 
lutely harmless to the instruments, however delicate they may be. It 
is indeed well known that when prismatic cystoscopes are allowed to 
remain in a trioxymethylene (iDaraform) sterilizer, the optical portion 
undergoes changes Avliich render them unfit for service. With this 
apparatus, to the contrary, instruments never undergo the slightest 
change as a result of the sterilization; this is accomplished, as above 
mentioned, in fifteen minutes. 

Cystoscopy is best performed in a darkened room. The c^^stoscopic 
pictures will thus be found much clearer and brighter. 

Preparation of the Cystoscope. — The instrument should be tried 
before it is sterilized and the operator should be certain that all its 
parts are in good condition. 

1. Testiis^g the Optical Apparatus. — The visual field of the in- 
strument should be very clear and should give exact and precise im- 
ages. The prism and the ocular should be in perfect condition and their 
surfaces brilliant and dry. The outer surface of the prism or of the 
lens is occasionally affected by moisture. When this is only on the 
outside, it is easily remedied by cleaning the glass with a fine cloth or 
with chamois. When, however, the moisture has penetrated into the 
interior of the cystoscope, and has reached the inner lens, the cysto- 
scope must be repaired so that perfect clarity of the lenses and prism 
may be assured. 

In cystoscopes with a movable ofjtical system, the latter possibly 
may not correspond exactly with the window of the instrument into 
which it is inserted. This verification should be made before the 
cystoscope is used. 

2. Testing the Electric Current. — The lamp should give a good 
white light. The intensity of the current should be increased until it 
is no longer possible to distinguish the handle of the metallic filament 
in the single mass of light. When the lamp does not light up, the cause 
should be sought; first, at the source of the current, next, at the con- 
ducting wires, and then at the rotating contact of the cystoscope. At 
the last mentioned point, there are two especially delicate places. One 
is the interrupter, where the groove or slide may be somewhat loos- 
ened, thus preventing the transmission of the current. The interrupter 
may be dirty or rusty or perhaps some dust has slipped under it. These 
parts must be cleaned scrupulously. When the current does not pass, 
a little pressure on the interrupter will produce an illumination, which 
ceases as soon as the pressure is released. 

The second cause of interruption of the current at the rotating 
contact is found when the conducting wires at this point are loosened 



TECHNIC OF IXDIIIKCr \ISI()X CYSTOSCOPY 



183 



or l)rok('ii. Slioi'l iiitcri'iiplioiis of llic (•uitciiI arc produced wliicJi 
result in a llickcriii,!;- of llic li,L;li1, lliiis makiii.L:- the examination ex- 
tremely annoying. At t]ie least movement the lamp goes out, only to 
])econie relighted ijnmediately, and it is ntterly impossible to make a 
satisfactory examination in these circunistances. A x)oor contact he- 
tween llie arms of llic coiiiacl and llic I'iiigs of llie cystoscope, may also 
produce this condition. These ti'oubles are best avoided by keeping the 
instrument and its attachments in a state of perfect cleanliness and 
repair. 

The interior conducting Avires also should lie tested and vci-ified; 
likeAvise, the lamp itself, by loosening the lani]), and bringing it in con- 
tact Avith the Uxo branches of the contact. If this is in good condition, 




Fig. 125.- — Indirect (prismatic) cystoscopy; position of operator and patient. 



illumination should result immediately. It is also Avell to assure one- 
self that the lamp is quite cold, and ayIII not burn the vesical mucosa. 

Preparation of the Patient. — All the clothing but his shirts should 
be removed; he should lie on his back, the knees bent and wide apart, 
the feet resting on stirrups, the buttocks slightly raised and brouglit to 
the edge of the examination table. 

Before the examination, the operator should have made certain 
that the urethra is permeable Avitli an olivary bougie, No. 23. If stric- 
tures are present, they should he dilated before anything further is 
done. The bladder should have a capacity of at least 80 e.c, and even 
with this mininunn capacity, vision is almost always difficult. It is a 



184 CYSTOSCOPY AI^D URETHROSCOPY 

well-established principle, therefore, not to attempt cystoscopy in an 
inflamed bladder without having submitted it previously to appro- 
priate treatment so as to increase its capacity. 

When an immediate examination is necessary, it Avill be well to 
diminish the sensitiveness of the bladder by instilling into it two grams 
of antipyrin and ten to tAvelve drops of laudanum half an hour be- 
fore the examination. Local anesthesia obtained by the use of a sterile 
1 per cent solution of stovaine in the bladder, will also be useful, but 
one should not depend too much on its effect. As a last resort general 
chloroform anesthesia may have to be emplo^^ed. 

Finally, the vesical medium must be transparent. Copious irriga- 
tion with tepid boric solution until it returns perfectly clear will bring 
this about. 




Fig. 126.- — Application of the indirect cystoscope (Nitze). 

In hematuria of vesical origin, irrigation with hot boric solution 
often stops the bleeding long enough for the examination to be made. 
In more obstinate cases, recourvse may be necessary to a 5 per cent so- 
lution of antipyrin of which 40 to 60 grams are instilled into the blad- 
der and allowed to act on the vesical mucosa for some minutes before 
the examination. Two or three instillations of the following solution 
may be made, taking the precaution not to let it remain in the blad- 
der longer than a few minutes: 



Antipyrin 


40 gm. 


1:1000 solution of adrenalin 


100 drops 


Distilled water 


1,000 gm. 



Occasionally it will be necessary to use the irrigating cystoscope 
and to renew the bladder fluid several times during the examination. 



TECHNIC OF IXI)IIJE(,'T VISION CYSTOSCOPY 



185 




Fig. 127. — First step in the introduction of the indirect cystoscope. The instrument is inserted into the 

urethra parallel to the inguinal fold. 




JFig. 128,. — Second step in the introduction of the indirect cystoscope. The instrument and the p^nis are 
held in a plane perpendicular to the axis of the pelvis. 



186 CYSTOSCOPY AISTD URETHROSCOPY 

Technic. — The operator begins by filling the bladder with warm 
boric solution or simply sterile water, avoiding the introduction of air 
into tlie bladder. [In the United States, a popular medium ft)r filling 
the bladder is a solution of 1 :5000 of oxycyanid of mercury. This is 
sterile, antiseptic, and nonirritating. — Editor.] The quantity of fluid 
in the bladder should average between 150 and 200 c.c. Too much fluid 
might cause distention of the vesical walls and in consequence would 
increase the distance to the object to be examined; if on the contrary, 
insufficient fluid is injected, the walls of the bladder would be brought 
too near the beak of the instrument and tliis would prevent the easy 
manipulation of the beak, and thus obscure the view. 

IntroductiojSt of the Cystoscope. — The slightest traumatism pro- 
duced in the introduction of the cystoscope is sufficient at times to pro- 
voke a hemorrhage. If the bleeding obscures the prism, which is quite 
certain, it will surely mar the clearness of vision, whether the blood 
clouds the vesical fluid or merely because of a little blood clot adherent 
to the prism; in either event, the visual field is obscured. The cysto- 
scope should be introduced into the urethra and bladder delicately, 
slowly, and gently. The accompanying illustrations will readily show 
the necessary maneuvers in the introduction of the instrument. Sev- 
eral distinct steps may be recognized: 

First Step. — The operator places himself at the left of the patient, 
holds the cystoscope in his right hand, takes hold of the penis with his 
left hand and raises it so as to obliterate the penoscrotal angle. The 
beak of the instrument previously lulnicated with sterile glycerin en- 
ters the "meatus and gently follows the entire penile portion of the 
urethra, taking as its guide the inguinal fold, to which the penis and 
cystoscope are made parallel (Fig. 127). The gradual introduction of 
the cystoscope is made evident by the indicator button on the ocular 
of the instrument. In this first step the button indicator should like- 
wise be directed towards the inguinal fold. 

Second Step. — As with the introduction of a sound, the second step 
consists in bringing the cystoscope and the penis back to the median 
line, in a plane perpendicular to the pelvis (Fig. 129). The penis is 
still held in the left hand, and the cystoscope descends into the urethra 
by its own weight so that the beak engages the membranous portion 
of the canal. 

Third Step. — The fully extended penis is now gradually lowered 
until the cystoscope is depressed slightly below the horizontal (I'ig. 
130). At this moment the operator takes hold of the penis and the 
cystoscope with the right hand, while the left hand makes flat pres- 
sure on the pubic region. This loAvers the suprapubic ligament and 



TECTTNTC Ol" IN'DIIIKCT VISION CYSTOSCOPY 



18" 




Fig. Ijy. — Tliird steji in the introduction of the indirect cystoscope. The left hand draws the penis 
upward, while the right hand holds the instrument vertically and perpendicular to the axis of the pelvis.^ 




Fig. 130. — F'ourth step in the introduction of the indirect cystoscope. The instrument and the 
penis arc depressed between the thighs of the patient; the righ^: hand gently inserts the instrument; the 
left hand makes pressure in front of the jiubic region, su as to lower the subi'ubic ligament. 



PLATE XI 

Fig. l.—Sillc thread seen in the bladder. This silk thread was used for a 
vesicovaginal fistula following childbirth. It is curious to observe that 
the knot is found on the vesical side and not on the vaginal aspect 
where it was originally tied. 

Fig. 2.— Syphilis of the Madder, showing bullous edema of the vesical mu- 
cosa. This condition seen in a patient of Jeanselme, came on coin- 
cidently with a secondary syphilis. While the patient still presented 
the roseola, she consulted me because of cloudy urine, and I found the 
lesions presented in this illustration. Examination made fifteen days 
later, during which time specific treatment had been given, showed that 
the bladder was restored to the normal condition. 




Fig. 1. 




Fig. 2. 

PLATE XI 



DIFFICULTIES OF PRISMATIC CYSTOSCOPY 189 

])('i-iiiils tlie cystoRCOiDe to slij) casil}' iiilo IIk- prostatic region as far as 
tlic l)]adder. Tlial the instniineiit is in the Madder is shown when 
its beak can Ix' lotatcd freely without any resistance being felt. Tlie 
i^ix'atost difificiilties ai'e eiicoiuitei-ed Ix'tweeii the second and third steps, 
])artieuUirly in eases of tuberculosis and hy})erti'0])liy of the prostate. 
Once the cystoscope has been introduced into the bladder, the ro- 
tating contact which carries the current is attached to the instrument, 
and the lamp is lighted. The latter should always be kept away from 
the vesical wall and should never touch it directly. The complete ex- 
amination of the bladder is then made. 

REFERENCES 

iLiiys: La Clinique, July 13, 1900, p. 453. 

-SiKiiez (le Mendoza: Trans. XIV Inteniat '1 Congress at Madrid, Section of General Surgery, 
1904, p. 493. 

DIFFICULTIES OF PRISMATIC CYSTOSCOPY 

Some of the difficulties that render cystoscopy unsatisfactory are 
due to the patient and others to the instrument. 

Difficulties Due to the Patient 

1. Nervousness of the Patient. — Often the patient is in such a state 
of fear, that he treml)les all over, thus making the cystoscopic exam- 
ination extremely difficult or impossible. It is well to gain his con- 
fidence by exi)laining what is to be done for him and by showing how 
useful the examination is going to be. It seems of small consequence, 
but it is very important not to light the lamp in the sight of the pa- 
tient; for he is apt to believe that the lamp is going to burn him or 
])urst inside of his bladder, thus adding considerably to his fears. 

2. Inflammation of the Urethral Mucosa. — The urethra may be in- 
Hamed and iiresent a more or less acute discharge. When the inflam- 
matory lesions are recent, cj^stoscopy must be postponed so as not to 
increase the existing inflammation. 

3. Atresia of the Urethral Meatus. — In this condition there are two 
courses to pui-suo: If the meatus is so narrow that it admits no instru- 
ment greater in caliber than No. 15 Charriere, meatotomy must be per- 
formed; or, as is more frequently the case, the meatus may be some- 
what larger and will admit a No. 18 sound, but the introduction of the 
cystoscope causes considerable pain. In the latter circumstance, insert 
a little taiii])()n of cotton satuiated with a few drops of 10 per cent 
stovaine solution into the meatus and the fossa navicularis: dilate with 



190 CYSTOSCOPY AND URETHROSCOPY 

a metal dilator, similar to the one devised by Howard Kelly, and by 
gentle stretching, the cystoscope may be gently introduced. 

4. Spasm of the Bulbomembranous Urethra. — In nervous patients, 
•we frequently meet with a reflex spasm of tlie membranous sphincter 

which may Be violent enough to completely prevent the introduction of 
the cystoscope. This may be overcome by lowering the head of the pa- 
tient to the horizontal plane, bending the thighs on the pelvis, and hav- 
ing the patient breathe deej)ly and slowly. Finally, if these measures 
do not succeed, relaxation may be accomplished by injecting 10 c.c. of 
a 1 per cent stovaine solution into the anterior urethra. 

[The editor usually overcomes this spasm by introducing a few 
alypin tablets into the deep urethra by means of Bransford Lewis' 
tablet depositor; this not only breaks up the spasm, but at the same 
time produces an excellent anesthesia of the deep urethra, and thereby 
facilitates the examination considerably. — Editor.] 

5. Urethral Stricture. — (3ccasionally a stricture of the urethra pre- 
vents the introduction of the cystoscope. In these cases, the urethra 
must be dilated until its caliber is sufficient to admit the passage of the 
instrument comfortably. 

In tuberculosis of the kidneys or of the prostate associated with 
cystitis, the posterior urethra and the membranous portion are often 
the seat of an inflammatory tuberculous process which causes altera- 
tions of the mucosa, thus preventing the comfortable introduction of 
the cystoscope. V\^hen the instrument reaches these parts bleeding en- 
sues, which not only increases the pain but likewise obscures the prism 
and makes vision extremely difficult or altogether impossible. In such 
instances, slow and methodic dilatation should be instituted and the 
greatest gentleness should be exerted when the cystoscope is subse- 
quently introduced. 

6. Prostatic Hypertrophy. — In this condition, the canal is de- 
formed and the cystoscope is forced to open a way for itself across the 
displaced prostatic lobes which are hypertrophied and usually con- 
gested. Here again, it is absolutely necessary to proceed with the ut- 
most gentleness possible, so as to avoid trauma and hemorrhage. 

7. Diminished Bladder Capacity. — Occasionally the bladder has 
not the iDroiDer caj^acity for its imfolded walls to be sufficiently distant 
from the prism of the cystoscope. For good cystoscopy, it has been 
determined there should be 200 c.c. of fluid in the bladder. Even with 
but 80 c.c. cystoscopy can be performed, but when the capacity falls 
below 60 c.c, the difficulties assume such grave proportions that any 
attempt at c^^stoscopy must be abandoned. In these cases, the under- 
lying C3^stitis must be treated first, by irrigations or injections, and the 



DIKFIcri/riKS Ol' I'IMS.MATIC C\ST()M'()P\ 191 

('yslosc'()i)i(' t'xaiiiiiialioii j)()si|)()ii(M| to a siiltsciiiicnl tiiiK! when lliu 
hladdoT" miioosa lias l)(H'()mo suniciciilly caliiKMl. 

S. Contraction of the Bladder. l^'r'Mniciilly, ilic palicnl siiddcnl) 
l)(',i;ii!s lo colli raci llic hladdci' iii\'()luiilai'il y dui'iii<i,' cystoscopy; juii-- 
ticularlx' is this true in nervous women. Tlic cxainiiialion is 11ins I'cn- 
dcrcd ini])()ssil)lc. ^'lic iiisl i-unicnt should Ix' taken out (jiiickly and tlie 
examination deFen-ed to a late)' sittin.i;'. 

{). Opacity of the Vesical Medium. — Tlie vesical fluid may l)e 
made tui-1)id by tlie presence ol" pus or blood. This occurs in liema- 
luria or ])rofuse renal pyuria, in whicb two or tlii'ee nroteral omissions 
suffice to completely obscure the fluid in the bladder. In these cir- 
cumstances the experienced cystoscopist employs his entire skill so as 
to be able to look ([uickly and to make his diai^nosis as to the cause of 
I lie ti()u))le during an unexpectedly good momentary view. In other 
circumstances, tlie operator will be obliged to use the irrigating 
cystoscope. 

Difficulties Due to the Instrument 

1. Failure of Illumination in the Lamp. — This is an extremely dis- 
agreeable occurrence. One sliould always have several reserve lamps 
at hand in order to make a change when necessary; it is better still to 
have other cystoscopes on hand, sterilized and ready for service, as a 
precaution against sepsis in changing the lamps. 

AVhen illumination fails, the fault is not always in the lamp neces- 
sarily; the other points of contact must be examined carefully, espe- 
cially at the handle and at the rotating contact and interrupter. It is 
well to remember that only a very slight failure of contact is sufficient 
to interfere with the required illumination. 

The electric contact, as is well knoAni, is made by a metallic 
"spiral," the elasticity of which assures the continuity of current be- 
tween the bod}^ of the cystoscope and the filaments of the lamp. AVhen 
the lani]) does not give a proper light, it is often sufficient to stretch 
or lengthen this little spiral with a pair of foi-ceps and this will restore 
the ])assage of the current in the lamp. 

2. Obscured Vision. — Cloudiness of the ])icture during cystoscopy 
ma\' be due to difTerent causes. The ])rincipal and most frequent is 
the result of faulty introduction of the cystoscope. When tiie opei'ator 
is not skillecl, he is a})t to introduce the cystoscoije not far enough into 
the Idachler. In these circumstances, he liuds himself ])luiig(Ml in dark- 
ness and sees ahsolutelN' nothing. To ohtain a clear \"ie\v the cystosco])e 
should be pushed a little further into the liladder cavity so as to get 
I'm' of the prostate and hiadder neck. 



192 



CYSTOSCOPY AiSTD URETHROSCOPY 



The reverse may also occur. AYheii the cystoscoiDe has been in- 
serted too far into the bladder, it is surrounded with vesical mucosa as 
in a hood (Fig. 131), with the result that nothing can be seen. *lBy with- 
dramng the instrument a little, thus freeing the beak, the \T.ew be- 
comes clear again. 

3. Spots in the Visual Field. — Tliis is unfortunately a rather fre- 
quent occurrence, met with especially when the instrmnents have beeu- 
used for some time. When the spots are found on the ocular or on the 
prism, it is easy enough to remedy this condition, but at times the 
damage is more serious and the instrument must be repaired at the 
factory. These spots on the optical apparatus were cpiite frec|uent 
when the instruments were sterilized in triox\'metliylene (paraform) 
vapor. A^^ien prismatic cystoscopes are permitted to remain in con- 




Fig. 131. — Faulty introduction of the cystoscope, which is covered by the mucosa as with a hood. 



tact with this vapor for some time, the held of vision usually ])ecomes 
clouded; for this reason, I recommended long ago, a specual ai3i)aratus 
for sterilization of prismatic cystoscopes (Fig. 124). 

4. Opacity of the Vesical Medium. — The difficulties which are the 
result of marked hematuria or pyuria, and which make the vesical 
medium opaque, will usually be avoided by the employment of the 
irrigating cystoscope. 

5. Opacity of the Window of the Prism. — Unfortunately even 
Avhen the cystoscope has been introduced into the bladder correctly, the 
operator often tinds it impossible to get a clear image, because in 
passing through the urethra the jDrism has been soiled with blood. 
This is encountered quite frequently in connection with hypertrophy of 



CYSTOSCOPY IN CHILDREN 193 

llic prostate, wliii-li hlccds easily and thus soils llic prism, TIk; irri- 
gating prism is extremely useful in these cases. 

Finally, other complications may rise from the optical apparatus, 
— the lenses may get out of order or the diaphragm may encroach upon 
the visual field. All these conditions are due to the wear and tear of 
the iust luiiieiits and require attention at the hands of the manufac- 
turer. 

CYSTOSCOPY IN THE FEMALE 

In the female, cystoscopy is much siinj)ler than in the male, because 
the female urethra is shorter. The cystoscope is generally introduced 
without any difficulty; hut cases occur, however, in which the meatus 
is narrowed by stricture, and this must he dilated. Local anesthesia 
may he produced h}^ inserting in the urethra a pledget of cotton satu- 
rated, with several drops of a 10 per cent solution of stovaine. [A 2 per 
cent solution of alypin or novocaine is highly satisfactory- for this pur- 
pose, without the risk attending the use of stovaine. — Editor.] 

Dilatation of the urethral meatus should he carried out AA'ith ex- 
treme gentleness, for a considerable amount of dilatation is not essen- 
tial. Furthermore, since this is usually followed by slight bleeding, 
gentleness is required so that the prism of the cystoscope shall not be 
blood stained in passing through the urethra. 

CYSTOSCOPY IN CHILDREN 

Because of the small caliber of the urethra in the child, it is neces- 
sary^ to use specially constructed cystoscopes particularly in boys. In- 
struments have been made exceedingly small, with a caliber correspond- 
ing to No. 15 Charriere; and '^^ith these instruments it is possible to 
make a fairly satisfactory examination in children. 

In girls, the urethra being short and much more easily dilated than 
in boys, the use of cystoscopes of reduced caliber will not be nearly so 
frequently required; in boys, however, it is sometimes impossible to 
get along without these special models. It goes without saying, that the 
visual field in these instruments is necessarily limited. Besides, they 
are fragile and much more delicate than the ordinary cystoscopes. 

CARE OF THE CYSTOSCOPE 

The indirect A'Ision cystoscope requires a great deal ol* care and 
should be kept perfectly clean. It slioidd be protected against jan-ing 
and against dust and danqmess. Xothing is more uiqileasant than find- 
ing one's instrument unfit for use when it is needed. 



194 



CYSTOSCOPY AND UEETHEOSCOPY 



As regards the catheterizing cystoscope, the ureteral attachment 
is washed freely with water immediately after use ; it is well to cleanse 
the entire instrmnent thoronghty with soap snds. The nreterahportion 
and the rubber cap should be boiled in water and the rest of the instru- 
ment cleaned inside and out with oxycyanide of mercury solution or 
alcohol ; but the latter should not be permitted to remain on the prism 
for it might loosen it. The cystoscope and all its accessories are then 
thoroughly dried, the ocular well corked and put away in a dry place. 

ADVANTAGES OF INDIRECT VISION 
(PRISMATIC) CYSTOSCOPY 

The prismatic cystoscoiDe has distinct advantages. This marvel- 
ous instrument offers a clean-cut thorough examination of the bladder 
combined with a large visual field (Fig. 132). A large area is brought 




Fig. 132. — lyarge visual Held of iS'itze's cystoscope. 

into view, not a small spot, thus making a general examination easily 
possible. If a tumor is present, its general relations, its surface and 
sometimes its implantation can be plainly seen. 

A second great advantage is that the caliber of the instrument is 
diminished and that it is introduced into the bladder with comparative 
ease. The two great advantages of this method are, therefore, the 
reduced caliber of the instrument and the large area of the visual 
field, which brings a considerable portion of the vesical mucosa within 
range of the eye. 



DISADVANTAGES OF INDIRECT VISION CYSTOSCOPY 

1. Considerable Experience Is Required. — It is impossible for a 
novice to make a successful examination the first time he uses this 



DISADXAXTACICS OK INHIItKCT VISlOX CYSTOSCOPY 



.lO.-) 



Iiisl niiiiciil : ill order lo cstiihlisli n (lia,!j,-ii()sis in accord willi llic data 
|)rcscnl('(| l)y Uic iiisl rimiciif , it is ahsoliildy necessary 1o he well ac- 
cuslonied lo <'\sl()scopic manipulation. 

The iioxice must train his oyc and iiis liand; liis oyo, in oi-dcr to 
learn how lo looiv at tlic iina,i;-(^ and to give; it a correct interpretation; 

his hand, so as to be able to place the instrument 

A^^: ^B jj^ ^ proper position; that is, neither too t'ai- 

<Nv / / i'l'om nor too neai' the ol).ject. 

2. The Image Is Reversed and Deformed. — 
Pi'imai'ily tlie pi-isin reverses tlie picture, hut in 
the vertical plane only. In the transverse phine, 
on the other hand, the image maintains its real 
position. In other words, the eye sees on the 
right side what is really on the right side, and 
on the left what is actually on the corresponding 
side. On the other hand, what is actuallj^ in 
front appears posteriorly and the posterior por- 
tions of the image appear anteriorly. 

In order to understand the deformities caused by the cystoscopic 
l)rism, the laws of reflection in plane mirrors should be borne in mind. 




I'ig. 133. — Schematic repre- 
sentation of the reflection of an 
image in a plane mirror (Nitze). 





I"ig. 134. — Schematic representation of Nitze's system. 



Fig. 135. — Schematic representation of 
Xitze's system. 



It is well known that tlie image of an object ])laced in front of a i^lane 
mirror is seen at a point equidistant beliind the mirror; the image is 
syniiiieti-ical with the oliject. The arrow Af> (Fig. 1,",;^)' which is re- 
II<'<-1ed by the mirror il/xV is in realit\- seen in the points A'I>". 

in Figs. ];J4, i;];"), i:^(i, and i:'?,' it inav he seen how the imaii'es of 



196 



CYSTOSCOPY AND UEETHEOSCOPY 



the bladder are really perceived, according to the different ways in 
which the cystoscope is held. The lines ab represent the prolongation 
of the cystoscopic mirror; the arrow AB represents the object, and 
the arrow A'B' represents the real position of the image. It is thus 
understood hoAV the images seen through the cystoscope may be de- 



R/ 




Fig. 136. — Schematic representation of Nitze's system. 

formed and different from the reality. Even though the operator 
succeeds in understanding these inversions and in correctly interpret- 




Fig. 137. — Schematic representation of Nitze's system. 

ing them, the eye must, nevertheless, become accustomed to them only 
after considerable practice. 

The determination of the real size of the object is likewise affected 
by the deformity caused by the prism. According to the position of 



DlSADVANTAdE.S OF INIMKl'XT VISIOX CYSTOSCOPY 197 

the prism, more or less close; to tlic ohjccl in tlic hladdo", an image 
corrospoii(liii,i;ly largo will ])o obtaiiKMl. Considerable experience is, 
I lierel'oi-e, i'e(|uir(Ml to delcniiiiie wliai size to allrihule to a liiiiioi' ol' 
ilie hiaddei', for exami)le. Frank's cystoscoije lias obviat(Hl tlie lirst 
object ion l)y allowing- the object to be seen by corrected vision; never- 
theless, it has not i-emedied the second objection, for the portions 
nearest the 2:)rism aic considerably enlarged while those laitliest oCC 
are nmch smaller. [All American cystoscopes are now constructed so 
as to eliminate the reversed image. — Editor.] 

3. A Tolerant Bladder Is Required. — To ol)tain a good view, it is 
essential that the vesical walls be sufficiently separated from one an- 
other ; otherwise a dim and hazy view is obtained. Very often the 
bladder contracts very painfully in spite of the use of a local anes- 
thetic such as stovaine, and this renders the examination impossible 
notwithstanding all our efforts. The examination must then be 
abandoned. 

[General anesthesia may be resorted to in these cases with satis- 
factory results.^ — Edttor.] 

4. A Transparent Medium Is Required.— The fluid medium in the 
bladder should remain transparent throughout the examination. This 
essential condition is extremely difficult to attain, at times, Avhen we 
are dealing with a severe cystitis, profuse renal p3^uria, or hematuria 
of prostatic, vesical, or renal origin. It is but proper to add that 
these disadvantages are overcome by the use of copious irrigation; 
but there are cases in which the obstacles are absolutely insurmount- 
able and the examination must be abandoned. 

Attempts have been made to avoid this difficulty by filling the 
bladder with air under pressure, instead of water; this constitutes a 
medium which remains transparent constantly, but the view of the 
vesical walls is defective Avhen seen under these conditions. Xitze has 
advised against this method, insisting particularly on the fact that the 
vesical walls appear as though they were covered witli brilliant vainisli, 
thus making the examination difficult. 

It is impossible to obtain a clear view if the prism is too near 
the object to be examined; the instrument should be held at the proper 
distance. When this can not be done because of certain deformities 
of tlie bladder, vision through the cystoscope becomes extremely diffi- 
cult. This is frequently met witli in pregnancy. 

EEFERENCE 

iNitzc: LcliiLucli cler Kystoscopio, Wiesbaden, Bergman, 1007, pp. 12G, 127. 



198 CYSTOSCOPY AND UEETHROSCOPY 

THE NORMAL BLADDER AS SEEN THROUGH THE INDIRECT 
VISION (PRISMATIC) CYSTOSCOPE 

A^^len the cystoscope lias been introduced into the bladder and 
the prism is turned toward the roof, a bubble of air is seen, which 
indicates the summit of the bladder. Anteriorly, is a rather i^oorly 
illuminated depression. This represents the projection of the bladder 
above the pubis, and in the female constitutes the suprajoubic recess. 
Scattered throughout the vesical wall are blood vessels which radiate 
like stars. 

When the prism is turned do^wmward, the line of the interureteral 
ligament or muscle is plainly seen; this stands out clearly and promi- 
nently as a thin, well-illuminated band. 

Behind this line is a depression, which corresponds to the bladder 
fundus. Anteriorly, the trigone is seen, always more vascular. 

Turning the prism laterally, the side walls of the bladder come into 
view. In the female, because of the uterus, they appear dex^ressed and 
constitute the so-called horns of the bladder. 

The neck of the bladder deserves special attention. When the 
prism is turned superiorly the neck appears in the form of a crescent, 
Avith the convexity above, dark red in color; this tint being somewhat 
less illuminated, can always be differentiated from the ]3aler color of 
the rest of the bladder. Turning the cystoscoioe laterally, the bladder 
neck resembles a crescent shaped like the last quarter moon, the points 
of which are always less clearly defined. Finally, when the prism is 
turned downward, we find the lower part of the neck not so sharply 
outlined, with the result that the margin of the neck can not be so 
well differentiated. At this i^oint the neck does not project, but seems 
to be continuous Avitli the posterior urethra. 

Locating the orifices of the ureters is generally cpiite simple and 
easy. For this purpose the circumference of the ocular may be likened 
to the dial of a clock. Taking the little indicator button attached to 
the ocular as a guide, the beak of the cystoscope is placed to correspond 
to six o'clock on the dial; that is, turned entirely doAvnw^ard and on 
the median line. Having found the bladder neck, the instrument is 
pushed backward about 2^/2 centimeters; the instrument is then turned 
on its axis so that the indicator button corresponds to eight o'clock 
on the dial for the right side, and to four o'clock for the left side. Now 
we have the corresponding ureteral orifice. 

To examine the entire cavity of the bladder systematically, a cer- 
tain series of movements should be executed by the instrument: 1. An- 
teroposterior movements which bring the beak from the bladder neck to 



NOItMAI. IJI.ADDKi; SKi:x 'I'! I IK) I i; 1 1 CYSTOSCOPE ID!) 

the |)(»s1ci-i()i- l)la(l(l('r wall. 2. Rotai-\ ihonciiichIs ;n-()iiii<l the axi.s, the 
latlcr i-ciiiaiiiiii,i^- slat ioiiarx-. 3. Seesaw iiiovciiiciits, hy lowering and 
clcvatiiii;- llic ocular. 'V\\i- latter inoNciiiciits ai'e made I'roni above 
downward or laterally Trom side to side. These movements are pei-- 
haj)s the Jiiost important in ol)tainin<>- detailed eystoseo])ie ima.u'es. l>y 
noting the di (Tci-'Mit images obtained as a result of these movements 
of the cystoscope, a clear impression of the real size and location of 
the object is attained. 

Nitze lias described briell\' liow the different ])ai-ts of the hhid(h'r 
may ])e examined systematically and methodically, as foHows : 

1. The beak of the instrument having been introdncfnl into the 
hladder, it is pushed backward till it comes into contact with the por^- 
terior bladder Avail. 

2. The beak is now turned from the median line to the right at 
an angle of 45 degrees; the instrument is now l)rought forward toward 
the neck of the bladder. 

3. Having reached the neck, tlie beak is turned 45 degrees to the 
left; an effort being made to hug the left vesical wall as closely as 
possible, the instrument is again pushed backward to the posterior 
wall. 

4. Finally, the beak is again turned dowuAvard, and the ocular 
depressed; this movement permits the examination of the most im- 
portant portion of the bladder, namely, the fundus and the trigone. 
By making these movements methodically, the entire vesical mucosa 
can be examined, so that only the minutest portions can escape 
observation. 



THE PATHOLOGIC BLADDER AS VIEWED THROUGH THE 
INDIRECT VISION (PRISMATIC) CYSTOSCOPE 

Cystoscopy in Cystitis 

Acute Cystitis. — Cystoscopy should not l)e done in acute cystitis 
except in very exceptional circumstances, for this examination is apt 
to be more injurious than useful to the patient. In tliis acute condi- 
tion, the vesical jnucosa may be desquamated and ulcerated; the 
slightest contact of an instrument with the inflamed nmcosa is sufficient 
to provoke a more or less severe hemorrhage. Severe pain accom- 
panied by a mai'ked febrile reaction nia>' also result. In these cir- 
cumstances, the examination must l)e i)()stp()ned until the pain and 
fever have subsided through appropriate treatment. 

The inflamed nmcosa is generallv of a diffuse i-ed color, and turiiid 



200 CYSTOSCOPY AISTD UKETHROSCOPY 

like velvet; this condition being due to the loss of epithelium. The 
entire structure and consistency of the mucosa are altered. In this 
connection, Zuckerkandl, of Vienna, has shown that the bulb*" of an 
olivary bougie can be buried in the substance of the turgid vesical 
lining without injuring the mucosa. Invariably the inflammation takes 
place at the fundus of the bladder and is always more marked at this 
point. The pathologic alteration is in direct proportion to the inten- 
sity of the inflammatory process. The coloration varies from a very 
faint redness to a very dark blue, like lees of Avine, with all the inter- 
mediary shades. Even a beginner finds it easy to diagnose the presence 
of an inflanmiatory condition of the vesical mucosa, the inflammatory 
color of which contrasts strikingly with the smooth and brilliant yellow 
surface of the healthy mucosa. 

In acute cystitis, the blood vessels can not any longer be recog- 
nized ; the inflamed patches may be circumscribed or extensive. They 
manifest themselves either under the form of small plaques or of 
little round patches like small islands. In the early stages of cystitis 
the mucosa often has the appearance of a geographical map. The 
bladder is invariably dark red and the normal mucosa can not be dis- 
tinguished. At the same time, there is a swelling of the mucosa which 
frequently becomes edematous, the mucosa then seems to form little 
hills and valleys, and sometimes the inflammation is so great that it 
takes on a varicose or polypoid api^earance. The epithelium of the 
inflamed membrane soon exfoliates and this is followed hj ulceration 
and destruction of the mucosa. Simultaneously there is also produced 
a fibrinous exudate with considerable pus which floats about in the 
bladder fluid. The lighter purulent flakes float on top of the vesical 
medium; the heavier masses fall to the bottom of the bladder where 
they accumulate. This accumulation of debris may very often com- 
pletely prevent the cystoscopic examination, and it becomes necessary 
to change the fluid repeatedly or to employ the irrigating cystoscope. 

2. Chronic Cystitis. — As compared with acute cystitis, the princi- 
pal feature characteristic of chronic cystitis is that the inflammatory 
lesions, instead of being spread over the entire bladder and covering 
the mucosa uniformly, are, to the contrary, considerably circumscribed. 

As previousl}^ mentioned, the most important lesions are found 
usually at the fundus. A considerable difference can be noticed be- 
tween a fundus which shows important lesions and the apex, which has 
the appearance of a perfectly healtliy mucous membrane. The vesical 
mucosa may be red, the coloration being in direct proportion to the 
capillary engorgement. The arterial vessels considerably dilated and 
increased both in size and number, are tortuous and fade gradually 



rATIlOLOCIC IlLAIiDKIl SEEN TIIItOlIGIE CYSTOSCOPE 201. 

into the redder paiclies. Lillk; red stains ai'e ohseixcd upon Ukj ves- 
sels, wliieli, hy iiiiititi.i;-, increase tlio exleiil oT llie iiiilaiiiniatoiy plaques. 

Cli ionic cNslitis is characterized usually by tlio presence in the 
fundus ol' liltle niuslii'ooui-shapod G,'rowths of a reddish color, auiou^' 
Avhich exudini;' masses are found. At limes these excrescences take on 
rather considerable growth, even to the extent of resembling a real 
})apilhmia. 

Often, the mucosa is joale and anemic. This is due, according to 
Nitze, to the disappearance of the supeificial vessels of the nuicosa, 
probably as the result of the thickening of the epithelium A\liicli covers 
the blood vessels. "When the cajjillary vessels reappear under the in- 
fluence of proper treatment, a cure may be expected. 

The nmcosa may also take on the appearance of a mosaic (Plate 
XV, Fig. 2) ; the base is of a rose yellow color and the design of the 
mosaic is formed by the engorged vessels. In other instances, as Xitze 
has Avell demonstrated, the vesical mucosa resembles leather, with 
prominences which resemble heaps of wheat grains or lentils. iVt other 
times, the mucous tumefaction may assume marked proportions; i^ro- 
jections in the form of sausages (Nitze) may be seen prominently 
throughout the bladder upon the hyperemic mucosa. These projec- 
tions are not to be confounded with the bladder trabeculations; some- 
times they assume the form of a cockspur and are usually separated 
from one another by dee^D depressions. 

In more severe cases the bladder is covered by a great number of 
villosities which give it the appearance of a lawn; this type is known 
as ''villous cystitis." The cystoscopic picture is indeed striking in 
these cases, for these graceful villosities take on the same movements 
as are observed in a Avheat field moved to and fro by the wind (Xitze). 

Under the designation of "parenchymatous cystitis," Nitze de- 
scribes a pathologic condition of the vesical mucosa in which the entire 
wall of the bladder is completely changed by the intense inflammations, 
or those of long duration; in this condition because of the presence of 
scar tissue, the vesical wall can no longer distend itself without pro- 
ducing pain. In these cases some portions of the nuicosa are found in 
a highly inflamed condition, glossy, bright red, well circumscribed and 
without any special shape, surrounded by mucous membrane which is 
noi-mal, or l)ut slightly inflamed. The affected part seems very smooth 
and glossy, and upon its surface are seen little raised areas like grains 
of sand which are very red in color. AVhen such a bladder is filled with 
water and the patient sulfers very acute pain, the cystoscope shows a 
little crack or tear in the bright red glossy j^ortions in which bleeding 
takes place. This parenchymatous ty]ie usually culminates in a shriv- 



PLATE XII 

Fig. 1. — Xormal aspect of ihv neck of the Madder, when the tube of the 
direct vision cvstoscope has been deej)ly introduced: Bolow, on the 
first row, is seen the red fundus of the bladder, behind the line of 
which is distinguished a very small quantity of urine not yet evacuated. 
The rest of the figure represents the posterior and superior walls of the 
bladder less brightly colored. The vesical reservoir is then greatly dis- 
tended because of the reclining position. 

Fig. 2. — Aspect of the 'bladder, not well dilated by the reclining position. 

Fig. 3. — Pathologic aspect of the right ureter chronicaUij inflamed, under 
the influence of too highly concentrated urine. The lips of the ure- 
teral orifices are edematous and swollen and the same marked chronic 
inflammation is seen in the immediate region which the urine must fol- 
low in leaving the ureteral orifice. 

Fig. 4. — Aspect of plaques of simple chronic nontuhercidous cystitis seen 
with the direct vision cvstoscope. These plaques are frequently observed 
in chronic cystitis and are mucli more easily distinguished with the 
direct vision cystoscope when the tube is held in profile, than when seen 
in full view. This was a case of cystitis which had developed in a 
woman with simjile pyonephrosis, in which all the bacterial examina- 
tions and guinea pig inoculations were negative. 

Fig. 5. — View of a papillomatous tumor of the bladder seen with the direct 
vision cystoscope. 

Fig. 6. — Normal vesical wall in contraction. This view can not be observed 
well except with the direct vision cystoscope, for in indirect pris- 
matic cystoscopy, the walls are distended by the liquid and can not 
contract freely. In the lower pait of the figure, the interureteral mu- 
cosa is seen; in the upj)er part during a vesical contraction, the blad- 
der comes close to the extremity of the tube, and assumes the ap- 
pearance of intestinal convolutions. 




Fis. 1. 



Fig. 2. 





Fig. 3. 



Fig. 4. 





PLATE XII 



Fig. 6. 



rA'i'iioi.ocic iii.AiiDi'Mi S!':i<:x tii iiorcii ( asi'oscopi-: 203 

(;1('.(1 U]) l)lail(l<'i- mid is rr('(jii('ii1 1\- the I'csiill oT ;i 1 iilx'i'culous |)1-(K'('S.s. 

Follicular of ,i;i-aiiular cNsiilis is (|uil(' coiiiiiioii. It appears in the 
Toi'iii of a sul)('|)illirliai iiilill ration made uj) of lyiiiplial ic follicles wliicli 
arc Jillcd witli lymphoid cells. Occasionally these J'oUielcs are sepa- 
rated tVoiii one another hv" healthy tissne; or tliey may he vei'y close 
lo,<;-etliei-. Tliey sometimes consist ol* numei'ons little limpid N'csicles as 
larjj:e as lentils, sometimes smaller (Plate Xll, V'l'^. 4, and Plate XIV, 
Fi<>,-. 1). Tliey may also he disseminated over tlie entire mncosa, re- 
semhlini;' dro])s of water, clear as crystal. This is the condition w ITudi 
Ortli lias desio-nated under the title of ''PFerpes A^sicalis"' (Plate XIV, 
Fi^\ "2). These vesicles may resemhle caviar, or when larger, they may 
simnlate varioloid pnstnles (Nitze). These follicles, the contents of 
which may he clear, cloudy, or purulent, seem to have no very" distinct 
signiticance so far as the diagnosis and prognosis are concerned. 

It was formerly helieved that this form of gi-anular c^^stitis is en- 
countered in cases which are tuherculous in nature. Such is not the 
case, however; in many instances, this form of cystitis is met with in 
cases in Avhich there is not the slightest suspicion of tuherculous 
infection. 

In the case of a young woman with an enormous nontulierculous 
pyonephrosis Avitli chronic cystitis, examination of the centrifuged 
urine and guinea pig inoculations proved conclusively that tuherculosis 
was out of the question (Plate XII, Fig. 4). The patient Avas 
nephreetomized, and she recovered completely. The removed kidney 
presented no tuherculous lesions. Seen again eight years later, her 
hladder was in perfect condition and did not show the slightest 
trace of granular cystitis. Tuherculosis was, therefore, completely 
excluded. 

Gonorrheal cystitis is characterized 1)y the presence of circum- 
scrihed inflammatory plaques in which the hriglit red mucosa is covered 
with vessels gorged with hlood. These plaques are usually found 
around the neck of the hladder chiefly on the lower \\a\\. The epithe- 
lium is most often exfoliated and floats in the vesical fluid. 

Tuherculous cy^stitis often gives such a characteristic cystoscopic 
picture that the exact diagnosis can he made frequenth^ at the fii-^ ex- 
amination hy the expert eye. It is characterized in the early stages hy 
the ])i-esence ol' suiall elevations in the form of nodules the size of a 
pinhead or of a lentil, and of a red or l)rowii color. Facli of these 
nodules is at flrst surrounded with a cii'cle ol' veiy line blood vessels; 
thev soon hecome ulcerated, are I'ound or irregular in I'orm, and al- 
most entirely suri'ouiided l)y a vei'v red hordei-. These ulcerations fre- 
quently ha\'e the a])pearance ol' n liuger nail sciatch or dent; they are 



204 CYSTOSCOPY AND URETHROSCOPY 

arcli-sliaped and deep, affecting the vesical mucosa throughout its en- 
tire thickness. The base of the ulceration is wrinkled and dirty and 
yellowish in color. The edge of the ulceration is elevated lik^a ram- 
part, as if cut with a saw (Nitze). Immediately surrounding the ul- 
ceration the vesical mucosa is very red and thick; as many as five to 
twelve nodules and ulcerations may coalesce, forming herpetic groups 
separated from one another by a strip of mucosa which is sometimes 
entirely normal, at other times faintly reddish in color. 

The nodules occasionally present themselves in the form of a collar 
or ring; at other times they arrange themselves around a blood ves- 
sel producing the appearance of a branch of bilberry (Nitze). AVhen 
the nodules or ulcerations are fairly limited around the ureteral or- 
ifices, the opi3osite orifice being completely normal, the diagnosis of 
renal tuberculosis can be positively made by a simple cvstoscopy (Plate 
XVI, Fig. 1). 

Under the name 'S^esical leucoplakia, " Brick has described a 
cystoscopic appearance consisting of bright Avliite iDlaques which are 
elevated above an extremely red vesical mucosa. These plaques are 
very adherent to the underlying tissue ; if they are rubbed mth cotton, 
the deep-seated mucosa bleeds. When examined microscopically it 
can be seen that they are histologically thickened epithelium. A typ- 
ical vesical leucoplakia is seen in Plate XV, Fig. 1. 

"Bullous edema," described by Kollischer, is found particularly 
in women. It appears in the form of clear vesicles, the size of a grain 
of wheat or that of a small pea; they may also be found much larger. 
This condition is met with in phlegmasia of the uterus or of its adnexa, 
especially in cancer of the uterus (Plate XXI, Fig. 1, and Plate XXIV, 
Fig. 3) ; it is also found in certain cases of pyosalpinx. 

The catarrhal exudate which accompanies cystitis is more or less 
abundant according to the severity of the inflammation. Its compo- 
sition is almost constantly the same; masses of exfoliated vesical epi- 
thelium, leucocytes and red blood cells may always be found in it. 
"When the urine undergoes ammoniacal fermentation, the exudate be- 
comes more dense and contains both amorj)hous and crystalline salts. 
When purulent masses predominate in the catarrhal exudate, they may 
adhere to the surface of the mucosa and thus completely change its 
appearance. When, however, they become mixed with the vesical fluid, 
the latter becomes turgid and opaque. In mild cases the exudate con- 
sists of little masses of pus or mucus which cover a considerable por- 
tion of the bladder mucosa. These mucous masses are white or grayish 
in color, and often resemble snowflakes. When gathered together at 
the fundus they may be mistaken for a vesical calculus. In more severe 



PATHOLOGIC BLAIi|)i;i; SKi;.\ IIHIOUGII CYSTOSCOPE 205 

cases tlie oxudaic is seen in Ihc ronn ol' a iiicnilti'aiic wliicli Ix'coiiics (le- 
tac1i((l fioiii llie vesical wall IVoni lime to liinc and ci-osses tlie field of 
vision al)riij)lly like a siKcr lisli (Xitzc). Occasionally false mem- 
branes are seen adlici-cni lo Hie Ncsical Jiiucosa by one of llicii- mar- 
g'ins. Tlieir nnat.laclnMl poitions float freely in tlie vesical lluid lik(i 
a cui'laiti Mow ii l»_\' llic wind, oi' like a(iuatic plants (Nitzc). 

Cystoscopy in Bladder Tumors 

AViien a bladder tumor is comjjaratively small and does not bleeii, 
llic image produced in an indirect vision cystoscope is often very fas- 
cinating. The splendid outlines, the pinkish, bright red color, the 
fimbria; iloating freely in the fluid like seaweeds or like an octopus, con- 
stitute a sjDlendid jDicture. At times, the tumor is small and may be 
seen in its entirety in the visual field; at otlier times it is much larger, 
so that the cystoscope nmst be moved about in order to reveal the en- 
tire tumor. It is sometimes difficult to determine whether the tumor 
is pediculated or not, for the pedicle is frequently hidden by the mass 
of the tumor. There are cases, however, in wliich a pedicle may be 
assumed to be present by virtue of the fact that the tumor floats in the 
vesical fluid. 

On the other hand, when the tumor adheres closely to the vesical 
wall, and especially when arterial pulsations are visible, it is evident 
that the tumor is not pediculated. In certain instances when the tu- 
mor is very large, the most prominent j^ortion may escape observation 
entirely because of the complete darkness of the field. For example, 
a tumor is found on the right side of the bladder. The operator be- 
gins by introducing the cystoscope so that the lens and the lamp point 
upward ; the entire pale vesical mucosa can be seen perfectly. As the 
cystoscope is turned toward the right, the image becomes obscured 
progressively until total darkness supervenes and nothing can be seen. 
However, as the rotation toward the right continues, the lower part 
of the bladder comes into view with its normal mucosa. The dark area 
evidently corresponds with the most prominent portion of the tumor, 
which, coming closely in contact with the prism and the lamp, makes 
distinct vision imj^ossible. It is, therefore, necessary in these cases, 
to vary the position of the instrument in order to be able to appreciate 
the exact volume of the tumor. 

The differential diagnosis between a benign and a malignant tumor 
of the bladder can often be made by the cystoscopic view of the mass. 
A benign liimor is characterized by the villi Axliich we have already 
mentioned, — delicate, nndii])l(> and Iloating in the vesical fluid. These 
benign tumors are also characterized by the fact that they float about 



206 CYSTOSCOPY AND URETHROSCOPY 

in tlie bladder, being very light in weiglit. They often resemble cer- 
tain marine animals, in appearance, such as the anemone. They may 
resemble a bnnch of grass or moss; or they may have long and- narrow 
villosities; at other times they have the form of a leaf, a canliflower, 
a bunch of herbs, or an acjuatic lolant. When the tnmor is near the 
ureteral orifice, the ureteral ejaculation sets them in motion in the 
bladder fluid. At times, they may present movements synchronous 
with the pulse; this is an evidence of intense vascularization. Their 
color is generally rather pale, and varies from clear pink to a dark 
rose, with often an intermediary discoloration of red ecchymotic spots. 

Malignant tumors, on the other hand, are usually part and parcel 
of the vesical wall. They consist of large massive infiltrations in the 
form of hemispherical nodules or of irregular sY\"eJlings projecting very 
slightly from the surrounding vesical wall. Their surface is smooth 
or verrucous. When villosities are present, they are small and curved. 
They appear hard and firm, like wood, often in the shape of a potato; 
they are motionless and do not float. Their upper part or summit is 
often covered with whitish masses like a snow-covered mountain. This 
appearance is usually due to necrosis of the superficial portions of the 
tumor. AVhen these malignant neoplasms become ulcerated, they take 
on the apjoearance of a crater at the bottom of which are seen nodular 
granulations. 

The coloring of malignant tumors is also different from that of 
benign growths. Most of the time the color is much darker, — usually 
dark red, black, or violet, occasionally resembling the lees of wine. 
Finally, malignant tumors are never pedunculated and their bases ad- 
here closely to the vesical mucosa and are continuous with it. 

[Aiuerican urologists are prone to regard all bladder tumors either 
as actually or potentially malignant in character. A benign tumor 
of today may be the malignant tumor of tomorrow. Clinically the 
diagnosis is impossible; biopsy via the ojoerating cystoscope, often 
helps to clear up doubtful points, but even this method is o]3en to 
the objection that a tumor may not show malignancy in some por- 
tions, while other jDortions may offer absolute proof of its malignant 
character. Therapeutically the diagnosis may be made tentatively on 
the theory that benign tumors disappear under '^fulguration" and do 
not recur, while malignant growths are not affected by this method of 
treatment. The matter is still unsettled. — Editor.] 

Cystoscopy in Certain Anomalies of the Bladder 

1. Diverticulum. — This anomaly is met with especialh^ in the fun- 
dus and near the bladder neck. The mucosa which covers the interior 



rATii()i,(H;ic i;i..\hiii:i: si:i-:\* tii i;()i'(.ii cysToscope 207 

of llicsc (li\('ii iciil.T is ,i;('ii('r;ill\' siiioolli niid willioiil folds. At liiiics 
llicv limy l)(' (|iiil(' l;ii',i;(' and may i-csciiiIjIc sccoiidary Madilfi's. Soiiic- 
tiiiies tlicy ai'c lai'.uc ciiou.^li lo pcrinil llic inl rodud ion of the cysto- 
scope. 

2. Varices. — Avarices liavc hccn observed hy \^ieitel and Zncker- 
kandl, especially in ])]'e,i;iian('y. I liaxc ))eeii ahle to soe tlieni oi'teii in 
])reonaiicy, in tlie sei'vice of J>ar. Tliey iiuiy ])0 seen in men, and in 
women inde])endently of ijreftnancy, hut ([uite excejjtionally. Tlioy 
may cause iiemorrliage ((iuyon, LeFiir, Baraduc) grave enongli to ne- 
cessitate suprapubic cystotomy. In prostatic liypertropby, dilated ves- 
sels may be seen near tlie base of the i:)rostate. Viertel lias observed 
premenstrual hematuria. In these cases it is the parenchyma of the 
mucosa Avhicli bleeds and it is only very rarely that tlie blood may be 
seen issuin,^' fi'oni a blood vessel. 

Cystoscopy in Cancer of the Uterus 

The observations on the importance of cystoscopy in uterine can- 
cer^ which I ])ublished some years ago, have been confirmed by Cruet" 
and l)y Violet and Murard."" Bladder c^^stoscopy is absolutely neces- 
sary in uterine cancer, for the cystoscope determines the indications 
for or against liysterectomy. Indeed, nothing hut cystoscopy can tell 
us Avhether or not the bladder is involved in the cancerous process; 
moreover, if the ureteral orifices or the ureters themselves are seen to 
be compressed by the uterine cancer, it will indicate that the urinary 
function has been seriously compromised, thus constituting a distinct 
contraindication to surgical intervention. 

AVhen the neoplasm has passed beyond the limits of the uterine 
neck and the upper extremity of the vagina, it diffuses itself in the peri- 
cervical cellular tissue; the neoplastic granulations come in contact 
with the bladder and the ureters, comi^ress them, adhere to them, and 
invade them. These vesical adhesions make oj^erative intervention dif- 
ficult and may induce the surgeon to perform more or less extensive re- 
sections of the vesical floor, — resections which often pioduce the most 
deplorable results. AVe may, therefore, agree Avith Cruet, that the con- 
dition of the bladder is the determining factor as to whether a cancer 
of the uterus shall be operated uj^on or not. Cystoscopy, therefore, 
reveals the extent of the neoplasm and decides for us as to the advisa- 
bility or the facility of surgical intervention applied to the uterus. By 
showing that the bladder is normal, cystosco]n- will determine the 
character of the o])ei-ati()n nolwillisiandiiig niisal israc1oi\- clinical data. 
On the other hand, cystosco])y will reveal some cases to be ino])erable, 
when they seem clinically to be o]i(M"able. 



208 CYSTOSCOPY AND URETHROSCOPY 

Direct vision cystoscopy is to be preferred to any other method of 
examination of the bladder in cancer of the uterus. We have constantly 
employed this method in the observations which Ave have mStde, and 
which are mentioned further on (see page 234). 

REFERENCES 

iLuys: Verhandl. d. deutsch. Gesellsch. f. Urol., II Kongress in Berlin, 'Lei'pzig, Georg 

Thieme, April 19-22, 1909 ; Oscar Coblentz, Berlin. 
2Cruet: Ann. de gynec, Jan. and Feb., 1913, pp. 1 and 70. 
sViolet and Murard: Ee\Tie de gynec, Feb. 1, 1913, xx. No. 2, p. 129. 

Cystoscopy of the Cancerous Bladder 

Cystoscopy of the bladder invaded by cancer comprises the fol- 
loAving: 

1. Examination of the vesical mucosa. 2. Examination of the ure- 
teral orifices and ureteral ejaculations. 3. Catheterization of the ure- 
ters and the determination of the capacitj^ of the renal pelvis. 

1. Examination of the Vesical Mucosa. — 

Vascularization or the Mucosa. — When the bladder is at first in- 
vaded by the cancerous infiltration which has extended from the uterus, 
cystoscopy brings into view the changes which have occurred in the 
vessels of the mucosa. These occur principally at the vesical trigone, 
and consist in the beginning of an increase in caliber and quantity, 
being indicated by the presence of fine isolated hemorrhagic effusions. 
By their cohesion they give the vesical mucosa a congested appearance, 
made evident by an intense redness, which gives the vesical luucosa a 
dark ecchymotic or perhaps a violet tint. Here and there small ulcera- 
tions may be observed, buried amid a red and congested mucosa and 
showing minute hemorrhages (Plate XXI, Fig. 2). This explains the 
ease with which the mucosa bleeds when it comes in contact with a cot- 
ton carrier or with the cystoscope. The vesical surface looks raw and 
the epithelium is exfoliated. This is tlie first stage and may remain in 
this condition for a considerable period of time, the lesions are usually 
confined to the trigone. 

Edema. — Later on, edema appears in a more accentuated degree, 
this being the most usual accompaniment of cancer of the bladder. 
Edema is at first indicated by the presence of folds and swellings, which 
showing themselves first at the trabeculations, become more and more 
numerous and voluminous and end in the formation of more or less 
coherent edematous masses. Most of these edematous folds are found 
behind the trigone, at the fundus of the bladder. 

The cystoscopic picture varies according to the size and number 



PATIIOLOdlC l*,l.AI)i)l';n SI'IKX TII IMiI'I.II ('\ STOSCOPIi 209 

ol.' ilic'sc bodies. 'Tlic (mIciiijiIous N'csiclcs may he 1 1'aiislucciil and llicii' 
size may vary I'l^oin llial of a ])iidi('ad lo a .L-.rajx'. .\1 limes tliey are red 
and ecdiymotic; at otlier times, they resemble gelatinous balls, of a 
li,^'lit bine tint; ag'ain, tliey are joined too-otlier and form a whole, whieh 
Fromnie has described as resemblinii,' a cushion, l^hey may also be dis- 
seminated and separated by folds or by less edematous ])oi1ions (Plate 
XXT, Fig. 1, and Plate XXIV, Fig. 3)". 

AVhen the edema is extremely marked, it is termed "bullous 
edema," first described by KoUischer. This consists of a mass of clear 
vesicles, the dimensions of which vary between a pinhead and a large 
grape. 

Invasion of the Bladder by CancePw — Simultaneously Avith the 
edema, invasion of the vesical mucosa by the cancer may 'frequently 
be observed. This ajDpears at first in the form of little oval or round 
plaques the size of a pinhead, resembling candle drippings. Later on, 
the granulations become more red and constitute little nuclei Avhich 
appear prominently on the mucous surface. Or the cancer may mani- 
fest itself in the form of vegetations which form branching arboriza- 
tions; these are Avell shown in Plate XXI, Fig. 1. 

It is especially interesting to study the onset of cancer of the 
bladder with the direct vision cystoscope. With this instrument the 
bladder may be seen not only at full view but in profile, and under 
these conditions the slightest elevation of the mucous membrane can be 
readily observed. In a more advanced degree, nuclei are formed in 
the thick substance of the vesical mucosa; they are distinguished by 
their hardness and opacity, and especially by the extreme facility with 
wdiich they bleed on the slightest contact. 

Perforation of the Bladder. — When the lesion has developed for 
quite a long period, the result is almost certainly a perforation of the 
bladder communicating Avith the vagina. This perforation aj^pears in 
the shape of an ulceration almost entirely concealed by edematous 
masses or covered over by false, Avhite membranes. These A^esico- 
vaginal fistulas of cancerous origin are always indicatiA^e of an unfavor- 
able prognosis. 

Swelling of tpie Bladder Fundus. — German authors have at- 
tached quite considerable importance to the bulging of the fundus of 
the bladder, but it does not seem to me that this curvature of the 
A-esical Avail has any ])articularly specific meaning in the diagnosis of 
secondary invasion of the bladder by cancer. The simjile elevation of 
the bladder fundus indicates nothing ])ut tlu^ development of a mass 
behind the bladder. This is observed in pregnancy, as Avell as in retro- 
AHM'sion, lil)roma, and cancer. AVith the dii'ect A'ision cystoscope this 



210 CYSTOSCOPY Ai!^D URETHROSCOPY 

bulging is very seldom seen, because of the reclining position of the 
patient; in am^ event when it exists alone, it can not be considered as a 
contraindication to surgical intervention. 

2. Examination of the Ureteral Orifices and Ureteral Ejaculation. — 
Cystoscop}' enables one to investigate the condition of the ureteral 
orifices and of the ureters themselves Avith great precision. The ap- 
pearance of the orifices may be modified more or less by the presence 
of edema of the vesical floor. These orifices may become entirely invis- 
ible, depending on the extent of the edematous masses. At other times 
the orifices are more or less narrowed, swollen, enlarged, and their 
edges edematous. Enlargement of the ureteral orifice often indicates 
the presence of a stricture higher up in the canal. 

The study of the ureteral ejaculation is also of considerable, im- 
portance. It is best seen with the direct vision cystoscope. Indeed, 
with this instrument the emission can be seen in profile in the form of 
a very small jet of water; the intensity of this emission denotes the 
condition of the ureteral musculature. The emission should be stud- 
ied as to its rhythm and as to its sti^ength, 1)oth of which are subject 
to wide modifications. 

3. Catheterization of the Ureters. — ]\Iere inspection of the ureteral 
orifices is not sufficient; in addition, it is well to catheterize both ure- 
ters with fine catheters whenever it is possible to do so ; for in this way 
alone can we be assured of the free flow of urine in the ureters. Not 
infrequently in spite of the normal appearance of the ureteral orifices, 
a No. 5 catheter is arrested two or three centimeters from the orifice. 
This indicates that the ureter is being compressed or invaded by 
cancerous infiltration. When, in such cases, the catheter is left in place 
for a few moments and there is no escape of urine, a complete obliter- 
ation of the ureter is indicated, Avith exclusion of the kidney. 

In a case observed in the ser^dce of Pozzi, a patient Avith cancer 
of the uterus did not in the least suspect anything abnormal Avith the 
kidney, for she had ncA^er felt. anything Avrong in this connection; neA^er- 
tlieless, there Avas an obliteration of one of the ureters Avhich Avas 
bringing about a complete functional destruction of one of the kidneys. 

On the other hand, Avhen the catheter suddenly produces a copi- 
ous floAv of urine, after liaAdng progressed Avith difficultA" for a feAv 
centimeters into the ureter, Ave are dealing Avitli hydronephrosis due to 
a partial obliteration of the ureter. 

EsTiMATioi>f OF THE CAPACITY OF THE KiDNEY Pela^s. — Under the 
circumstances just referred to, — as I haA^e recommended since 1906,^ 
— an iuA^estigation should be made of the extent of the hydro- 
nephrosis, by determining the capacity of the renal i:)elvis; this re- 



PATIIOI.MCIC Iil.ADltKFl SEEN '11 1 Ko I 'CH CYSTOSCOPE 211 

veals tlic amouiii of dot iiiclioii of llic coiTcsiJOiKliii^- renal paroii- 
clixiiia. This esliiiiatioii oT llic |)('l\i(' ('a})a('ity (llic (lircclioiis and 
leclinic of wliicli arc doserihed later on) is made hy injecting- sterilized 
water into the pelvis by means of a ureteral catlieter syrin^-o. AVlien 
Hie pelvis becomes distended, tbe patient feels a well-defined Imnbar 
])ain wliicli is al)S()]utely eliaraeteristic. A note is then made of the 
(juantity of tlui<l that lias been injected. A normal pelvis contains 
about 5 C.C.; when more tlian 10 c.c. can Ije injected, bydronephrosis un- 
d()ul)tedh' exists. 

From tbe cystoscopic examination practiced in a metbodical man- 
ner upon all patients with cancer of tbe uterus, important conclusions 
can be drawn. AVitb this object in view, we have examined tbirty- 
tbree i:)atients witb uterine epitbelioma, in tbe service of Pozzi, Avitb 
tbe following results: 

The bladder Avas normal in seven cases; i. e., Nos. 3, 12, 17, 19, 20, 
22, 31. Among tbese seven cases, one is especially instructive, — case 
Xo. 20, in wbicli tbe cancer bad involved tbe posterior portion of tbe 
uterus especially, leaving tbe anterior portion unaffected. 

Tbe bladder Avas involved, tbe fundus being sligbtly inflamed in 
tbirteen cases; i. e., Nos. 1, 2, 4, 9, 13, 16, 21, 23, 24, 26, 28, 29, 33. 

The bladder was invaded by tbe cancer and presented, not only 
bullous edema over tbe entire fundus, but also a distinct elevation of 
tbe floor, in tbirteen cases; i. e., Nos. 5, 6, 7, 8, 10, 11, 14, 15, 18, 25, 27, 
30, 32. 

In one case, No. 14, a vesicovaginal fistula was noted. 

In one case, No. 25, we observed a compression of tbe ureteral ori- 
fices Avitli distinct and important effect on tbe kidney. Tbis case is 
an im^Dortant one, for tbis complication miglit pass completely un- 
noticed if proper care is not observed in tbe matter. Tbe conclusions 
resulting from tbe cystoscopic examinations in tbese cases are as fol- 
io avs : 

Conclusions. — 1. Bladder cystoscopy sbould l)e performed in all 
cases of uterine cancer, not only from tbe standpoint of operative prog- 
nosis, but also as an indication or contraindication for surgical inter- 
vention. 

2. If tbe blad<ler is free from all lesions or presents only a dif- 
fused redness or a sligbt bloody suffusion, operation is indicated and 
will not be difficult. 

3. If tbe bladder is somewbat involved, if little idcerations of tbe 
nuicosa and well-marbed vascularization are observed, tbe surgeon 
may expect tbat abdominal bysterectomy will l)e a difficult matter. 

4. If, finallv, tbe bladder is decidedlv attacked bv edema or by can- 



212 CYSTOSCOPY AXD UEETHEOSCOPY 

cer itself, or b}^ a vesical perforation, tliese must be considered as a 
contraindication to abdominal hysterectomy wliicli can onh" be done 
witli extensive resections of tlie vesical wall. *^ 

5. If the ureters have become impermeable through ureteral com- 
pression by cancer of the uterus, or if they become invisible because of 
the accomiDan^dng edema, operation is absolutely contraindicated. 

The following observations, the result of experience in the service 
of Pozzi at the Broca Hospital, have been published in greater detail 
in the thesis of M. Colaneri:^ 

Case 1.— Widow B., aged fortT-five. 

Exammation of the Uterus. — Xeck ulcerated, irregular, jagged, indurated, bleeding 
easily, painful; slightly mobile. 

Cystoscopy. — Fundus congested with red elevations as large as grapes, bleeding easily, 
indicating that the bladder is involved. 

Ureteral Orifices.— The right is quite small, a No. 5 catheter shows the ureter is patent 
and free; the left is quite small, a No. 6 catheter enters freely. 

Treatment. — Total abdominal hysterectomy. Uterus adherent anteriorly to the ex- 
treme limit of operability; uterine body separated from the neck during operation; ureters 
hard to find. Death the following day. 

Case 2. — F., aged forty-four. 

Examination of Uterus. — Nodular, but does not bleed. 

Cystoscopy. — Normal bladder capacity; fundus distinctly red; bladder is slightly af- 
fected; ureteral orifices normal; catheterization normal. 

Treatment. — Usual; complete vaginal hysterectomy. Went home in three weeks. 

Case 3.— T., aged fifty-one. 

Cystoscopy. — Bladder and ureteral orifices normal; on the left side, a No. 6 catheter 
is arrested slightly at 3 centimeters, but passes higher up, though with some difficulty. 
Treatmient. — No operation; went home. 

Case 4. — V., aged fifty-two. 

Cystoscopy. — The fundus is markedly congested and bleeds at the slightest contact. 
Ureters are free; bladder is involved. Passed from observation. 

Case 5. — Z., aged fifty. 

Cystoscopy. — The right fundus presents a few edematous masses near the right ureter ; 
both ureters are small, but permeable to No. 5 catheters. The bladder is involved. 
Treatment. — No operation; patient left the hospital. 

Case 6. — ^E>., aged forty-three. 

Cystoscopy.- — -Bladder capacity normal; at the fundus in the median line are found a 
hard elevation, hyperemia, congested mucosa with whitish vegetations which bleed at the 
slightest contact; on the lateral portions are edematous masses varying in size from a hemp 
seed to a large pea. Tliese masses cover a large part of the fundus and completely conceal 
the orifices of the ureters, which therefore can not be catheterized. The bladder is involved. 

Treatment. — No operation; went home in fifteen days. 

Case 7. — C, aged forty-one. 

Examination of Uterus. — Ligneous infiltration of two-thirds of the vaginal circumfer- 
ence; neck effaced. 



PATHOLOGIC BLADDER SEEX THROUGH CYSTOSCOPE 213 

Cystoscopy. — Edematous globules on the bladder floor; entire fundus is edematous; 
right ureteral orifice is noimal and readily accepts a No. 7 catheter; left orifice is over- 
hung by edematous masses which conceal it and make catheterization impossible. 

Treatment. — "Warm air; no operation; died a year later. 

Case 8. — M., aged forty-one. 

Examination of Uterus. — Xeck is hard, very much increased in size; anterior lij) over- 
hangs the posterior ; the orifice is linear, friable, and gives evidence of bloody debris. 

Cystoscopy. — Bladder capacity normal; on the fundus and the median line are large, 
transverse swellings of glossy edema; the remainder of the fundus has a granular aspect; 
the bladder is involved; the right ureteral orifice accepts a No. 6 catheter; the left is sur- 
rounded with a placque of leucoplakia but easily accepts a No. 7 catheter. 

Treatment. — Complete abdominal hysterectomy; no marked adhesions; slight bleed- 
ing; died the following day. 

Case 9. — B., aged forty-two. 

Examination of Uterus. — Enormous neck, hardened; uterus retroverted. 
Cystoscopy. — A diffused, generalized edema covers the fundus; the bladder is involved; 
ureteral orifices are small; double catheterization is easy. 

Treatment. — No operation; hot-air applications; went home a mouth later. 

Case 10. — H., aged thirty-six. 

Exa/mination of Uterus. — Neck ulcerated and bleeding; uterus immobilized. 

Cystoscopy. — The fundus is involved in glossy bullous edema, wliich bleeds at the 
slightest contact ; urine is clear ; the bladder is involved ; right ureter is somewhat swollen ; 
a No. 6 catheter passes easily; the left is surrounded by masses of bleeding edema; catheter- 
ization is impossible. 

Treatment. — No operation; left ten days later. 

Case 11. — B. M., aged thirty-four. Clinically, epithelioma of uterus. 
Cystoscopy. — The fundus presents numerous edematous globules with hemorrhagic spots; 
bladder is involved; ureteral orifices can not be seen. No treatment. 

Case 12.— C. M. 

Cystoscopy. — Urine is clear; bladder normal, with normal caj^acity; fundus and ureteral 
orifices normal; the left is simply a little elevated and enlarged. 

Case 13. — T. J., aged twenty-eight. 

Examination of Uterus. — A vegetating tumor, which occupies both lips of the neck, 
irregular, embossed, resting on an indurated base; the tumor is extending toward the left 
lateral cul-de-sac, where the uterus is fixed, though movable elsewhere; bloody debris. 

Cystoscopy. — Bloody' ecchjTnoses at the neck; fundus is distinctly red; between the 
ureters is a clearly detined inflammatory redness; the bladder is involved; ureteral orifices 
are normal, with feeble but normal emissions. 

Treatment. — Oct. 16, 1908, curettage; cauterization. Nov. 10, 1908: Total abdominal 
hysterecomy; dissection of ureters adherent to the parametrium and uterus; they had to 
be dissected with the knife; separation from the* bladder difficult. Kecovery in five weeks. 

Case 14. — G., aged thirty-three. 

Examination of Uterus. — Vaginal fundus indurated; cancerous buds, bleeding easily; 
vesicovaginal fistula invisible, but prolialjly situated at the left in the midst of the most 
numerous fungosities. 

Cystoscopy. — Urine is cloudy; no bladder capacity because of the vesicovaginal fistula; 
the fundus is invaded by the neoplasm and by numerous globules of edema; the bladder 
is greatly involved, except the roof, which is nornuil; ureteral orifices concealed by the 
fungoids which surround them. 



PLATE XIII 

Fig. 1. — Appearance of a ureteral orifice in pregnancy. The ureteral ori- 
fice, displaced by the fetal head, is situated higher than in the normal 
state; laterally a long j^assage which represents the right lateral side 
of the bladder is seen. 

Fig. 2. — Normal appearance of a ureteral orifice seen with the direct vision 
cystoscope, and isolated in the lumen of the cystoscopic tube. 

Fig. 3. — Ureteral emission of normal urine as seen with the direct vision 
cystoscope. 

Fig. 4. — Direct catheterization of the ureter with the direct vision cysto- 
scope. The fact that the catheter has penetrated well into the ureter 
can be verified by the double fact that it is fully surrounded with 
mucosa, and that the vesical mucosa is slightly puffed up around it. 

Fig. 5. — Tra'beculated bladder. Typical view. 

Fig. 6. — Urethrovesicovaginal fistula. View of the neck of the Madder. In 
the upper part of the figure the floor of the normal bladder is recog- 
nized in the distance, very poorly lighted; it is surrounded by the 
bladder neck, which is slightly furrowed and edematous. To the right, 
lateral side of the vesical neck (to the left of the oliserver), a large 
oblique orifice with edematous walls is seen, through which a catheter 
can penetrate. This orifice leads into a passage which, turning around 
the right side of the vesical neck, enters the bladder at the vesico- 
vaginal region, thus constituting a real fistula. 




Fig. 1. 



Fig. 2. 





Fig. 3. 



Fig. 4. 





Fig. 5. 



PLATE XIII 



Fig. 6. 



i'.\'i'ii()i-()(;i(' i;lai)|ii;i; si;I';x tii iiorcii ('\'st()sc"()PI': 215 

Tn III niciil. '\\\ tlis |iic\ iuiisly, tiit;il ;i lulnin i ii;i I li yst cici-l uiii y li;i<l Imtm iirrCiii-nK'd, 

J'lir very :iil\ ii iiri'd ciiil licliniii;! (if llic neck; tlic left iiirlcr \vas distciidcd hchiiid its i>()iiit 

III' |iciicl nil inn ill tile liiii;iil linn lit; riiiHici- dii, lilifiMin in size and adlirront to tlic mass. 

Krsccti r (lie iiirlrr iiiid a ii;isl iiiiMisis iiilii llic liladdcr wiiiTc Hir VL'sical rcsc'i-tiun liad 

IjCL'IL dniU'. 

Two nidiitlis later: Rcadiiii- and jiassiii;;- licyniid llic alTrctcd ;nca is iinpossihlc ; 
lips of tistula sutuii'd; tiu'iiiKu-aulcii/.tit inn of the Inids. Went Ikmih' four iiiontlis later. 

Case 15. — C. Z., aj;ed forty-seven. 

Examination of Uterus. — Neck covcied with IukIs; lilcrdin;;. 

Ci/sloscoiiii. — A liaiid nf edema is clearly seen on the intcrureteral muscle (li^iinient) 
half a centimeter in length; also some edematous masses no larger than a hempseed. The 
Madder is involved. 

Treatment. — Curettage and cauterization; went homo a nidiitli later. 

Case 16. — D. J., aged twenty-eight. 

E.mmination of Uterus. — Neck irregular and hard, espcidally the anteridr liji; uteius 
not increased in size, slightly mobile; cul-de-sac negative. 

Cystoscopy. — Within the left ureteral orifice, which is normal, there are a few de- 
tached globules of edema the size of a' millet grain, upon an abnormally red base; the 
bladder invasion is extremely limited and in its incipiency. 

Ureteral Orifices. — The right is normal; the left has some edematous masses around 
it ; emissions normal ; urine is clear. 

Treatment. — Total abdominal hysterectomy. Easy dissection of the ureters and blad- 
der, the latter very adherent. Went home one month later. 

Case 17. — R., aged sixty-five. 

Examination of Uterus. — Painful ; the neck forms a crater with torn and bleeding 
edges; uterus is immobile. 

Cystoscopy. — The mucosa of the fundus is contracted and in folds, but appears normal ; 
no edema; the right ureteral orifice is normal; the left shows some light false membranes; 
urinary secretion is the same on both sides, this being verified by the use of the separator 
(Luys). 

Treatment. — No operation. Went home two months later. 

Case IS. — L. J., aged forty-six. 

Cystoscopy. — The urine is cloudy; the fundus is edematous in jiarallel grooves and 
bleeds easily; it is elevated en masse, so that the cystoscope must be depressed considerably 
to enter the bladder. The bladder is therefore involved; only the roof is normal, and .shows 
no abnormal va.scularization ; the ureteral orifices are invisible, being hidden liy the edema, 
which has spread out over the entire fundus. No treatment. 

Case 19. — P., aged forty-seven. A characteristic uterine neoidasm. 

Cystoseopi/. — The urine is clear; the bladder and ureteral orifices are normal. Case 
not f(dlowed up. 

Case 20. — V., aged forty. Six months previously underwent removal of the neck of 
uterus because of ulceration. After this operation a fetid discharge and pain persisted. 
Manually, it was found that the posterior lip of the neck was completely ulcerated and 
that the obstruction reached the rectovaginal wall. In additimi, hard masses cduld be felt 
in the broad ligament. Uterus, iinnidbile. This examinnt imi slmwed thai the anterior aspect 
of the uterus was not involved, but that the cancer had devehiped pai t iciilmly along the 
]i(isteri(ir surface of the organ. 

Cystoscopy. — The bladder is quite noimal; the fundus but slightly reddened; ureteral 



216 CYSTOSCOPY a:sd ueethroscopy 

orifices entirely normal. In this case, therefore, the cancer had invaded the posterior por- 
tion of the uterus, leaving the anterior portion unattacked. Both examinations, manual and 
cystoscopic, agreed in the findings. This patient was not oj)erated on, and death followed 
two months later. **■ 

Case 21. — E., aged thirty-nine. Clinically, a neoplasm of the neck of the uterus. 
Cystoscopy. — The fundus is slightly inflamed, especially on the right side; right ureteral 
orifice is not well defined; it has torn and red edges. Case not followed up. 

Case 22.— F., aged forty-three. 

Examination of Uterus. — Neck fungous; culs-de-sac invaded. 

Cystoscopy. — Urine is clear; the bladder is normal and has normal capacity; ureteral 
orifices also normal. 

Treatment. — No operation; hot-air applications; curettage. Went home. 

Case 23. — S., aged forty-eight. 

Examination of Uterus. — Large neck with indurated areas ; uterus is mobile ; the 
broad ligament does not seem to be involved. 

Cystoscopy. — The fundus is noiinal except for some small elevations resembling grains 
of sand, which are usually met with in chronic cystitis. The roof of the bladder, on the 
other hand, presents numerous bright red spots about the size of a dime, and resembling 
purpura. The ureteral orifices are normal. 

Treatment. — Total abdominal hysterectomy; dissection of the anterior uterine wall up 
to the vaginal cul-de-sac; severe hemorrhage followed; difficult hemostasis. Went home two 
months later. 

Examination three years after operation: The purpura has disappeared; the bladder 
is normal. 

Case 24. — E., aged thirty-four. 

Examination of Uterus. — In the vagina, an enormous mass, budding and hard; the culs- 
de-sac are completely invaded, especially the right. 

Cystoscopy. — The urine is slightly hazy; bladder capacity normal; the right fundus 
is slightly elevated; on the same side are edematous masses, some of which are ulcerated, 
this being an indication of bladder involvement; both ureteral' orifices are in contact 'with 
these masses. 

Treatment. — Curettage and cauterization. Went home. 

Case 25. — D., aged sixty. 

Cystoscopy. — The trigone is invaded with a red tissue, with whitish ulcerated buds 
and bleeding easily; the urine is cloudy and the bladder is invaded; the right ureteral orifice 
is barely visible in the midst of neoplastic tissue; catheterization is impossible; the right 
kidney is plainly increased in size; the left ureteral orifice is normal. 

In this case there was a distinct contraindication to operation. 

Case 26.— F. S., aged thirty-one. 

Examination of Uterus. — The neck is vegetating and bleeding. 

Cystoscopy. — The trigone is bright red and elevated; slight elevations, somewhat paler, 
stand out prominently against a background of hemorrhagic spots; the bladder is but 
slightly invaded; the ureteral orifices are normal. 

Treatment. — Curettage and cauterization. Went home. 

Case 27. — L., aged forty-five. Neoplasm of the uterine neck. 

Cystoscopy. — The urine is clear; the fundus presents an intense generalized edema, 
contrasting with the glossy whiteness of the normal roof of the bladder; the bladder is 
undoubtedly invaded and painful; the ureteral orifices are invisible. No treatment. 



PATIIOLOCIC JILAItDKIt SliEN Tl I IM ) I ( i 1 1 ( ^ S'lOSCOPE LM 7 

Casio 2S. — 11., ajicd .sixt.y-oiic. Caiifor of tlic nli'iinc nci-k. 

Ci/s-toscopij. — The uriuo is dear; the l)lail<lri Hour is hij^lily vasfuilarizcd, ffathcrod in 
folds and Jidhcront, irscndjliiii;- tho intestinal nuiss; the hlailder is evidently involved; ureteral 
orifices are humikiI. Xu t icat nu'iif . 

Case 29.— B., aged forty-two. 

Exaviination of Vtcrus. — Neck situated rather hij;li up, hard and sclerotic; on the 
anterior lip are many buds, separated one from another by ulcers whidi Ideed very easily; 
culs-de-sac free, except at the left, where there is a slight thickening. 

Cystoscopy. — The bladder capacity is normal ; it is slightly invaded by neoplastic in- 
filtration; the trigone is slightly elevated and presents a hemorrhagic spot; the ureteral 
orifices are normal; nothing from the bladder point of view seems to contraindicate operation. 

Treatment. — Complete abdominal hysterectomy; the left adnexa adherent; isolation of 
the ureter; sc|)aration of the bladder and di.sscction by scissors of the lower extremity of 
the ureters. Went home seven weeks later. 

Case 30. — B., aged forty-four. 

Cystoscopy. — Urine is cloudy; the l)ladder capacity is 10 c.c. ; the fundus is markedly 
edematous; the bladder is affected; the right ureteral orifice is invisible in the midst of 
the edema. 

Case 31. — L., aged forty-nine. Cancer of the uterus. Has been referred to determine 
whether the bladder is involved. 

Cystoscopy. — The bladder is normal, bat presents numerous traljcculatiuns; the ureteral 
orifices are normal. 

Case 32. — B., aged thirty-eight. Operated on by Robineau, l)y the vaginal route, for 
an epithelioma of the uterine body. 

Cystoscopy. — Diffuse infiltration of the vesical mucosa at the fundus; liehind the fundus, 
highly edematous folds of the vesical mucosa are seen, which give the appearance of a large 
edematous cushion; the entire left side of the bladder is normal; two little transparent cystic 
vesicles are seen on the left lateral portion of the vesical neck; the ureteral orifices are normal. 

Treatment. — Local treatment of the bladder by applications of strong resorcin, with 
the direct vision cystoscope. 

Case 33. — Iv., aged fifty-two. Eeforrcd to determine whetlier site has a neoplasm in 
the bladder. 

Cystoscopy. — The bladder has a capacity of 150 c.c; tiic uiinc is clear; the fundus is 
slightly infiltrated, congested and downy; the ureteral orifices arc normal; the bladder is, 
tlierefore, but slightly involved. 

EEFERElirCES 

iLuys: De la mesurc de la capacite du bassinet, Ann. d. inal. d. org. genito-urin., lOOli, ii, 

p. 519. 
-Colaneri, X.: De la valeur de rexameii de la vessie daiis le cancer de 1 'uteru.'^, Tliese, 

Paris, Steinheil, Editor, 1913. 



CHAPTEE VI 
DIRECT VISION CYSTOSCOPY 

Direct vision cystoscoiDy is the study of tlie vesical mucosa under 
the direct control of the e^^e Avithout the aid of the prism or of any 
special optical apparatus. 

Under this head we shall consider: 1, The conditions necessary 
for the study of direct vision cystoscopy. 2. The teclmic. 3. The ad- 
vantages. 4. The disadvantages of this method. 

CONDITIONS NECESSARY FOR DIRECT VISION 
CYSTOSCOPY 

In order to see an object well in all its details, it is essential that 
(1) it should he well illuminated; (2) it should be well isolated from 
the surrounding jDortions; (3) its surface should not be covered over 
by any fluid so that there may be a homogeneous medium between 
the eye and the object, without change of the index of refraction; and 
(4) the smallest details should l^e distinguishable. 

Bearing these conditions in mind, there are four essentials to a 
good view of the vesical mucosa, as follows: 1. Projoer illumination. 
2. Distention of the vesical walls. 3. Aspiration of the urine as fast as 
it enters the, bladder. 4. Magnification of the image. 

1. Proper Illumination. — It goes without saying that an internal 
source of illumination, brought as closely as possible to the object to be 
examined, is by far the most desirable method at our command. I 
have made a series of experiments in order to assure myself of this 
fact. Holding a simple tube vertically, I projected into it the rays from 
a very powerful electric light situated outside of the tube. I thus ob- 
tained an illumination which gave a modei'ately good view at the 
lower end of the tube. On the other hand, I placed a very small lamp 
at the point to be examined, and obtained a very fine illumination, more 
intense than previously. It was quite natural to expect that this ar- 
rangement would furnish a much better illumination than that pro- 
vided by an external source, such as a frontal head lamp, for example. 

For the illumination of my cystoscope, I then adopted the prin- 
ciple of the small electric lamp situated at the vesical extremity of 

218 



DIRECT VISIOX CYSTOSCOPY 219 

the cystosco])ic lulx'. I li;iv<' (M.iili-ihulcd the following iiiipi-ovements 
to this nietliod of illuiiiiiialioii : 

'Pile lamp is nci'v small wliilc its luiiiii)oii< intensity is superior 
to those loniuM-ly used; not only does it iilunriiiate the portion of the 
mucosa Avliich is in direct contact witli the extremity of the tuhe, 
but it also projects luminous rays beyond tlie tube. When the Madder 
walls are distended, ^vitll the patient in the inclined position, tliey are 
fully illuminated, so that a distinct and clear-cut examination of tlie 
entire bladder is made possible. (Figs. 149-150.) 

The lamps, mounted on fine rods, are very easy to handle, and 
can be changed in a few seconds. 

They are attached to a metallic cap, filled with a nonconducting 
material, so that fluid can not penetrate and thus produce a short 
circuit. 

They have a voltage of two volts, and when new, are al)solutely 
"cold." They can be kept lighted between the fingers without any 
appreciable heat being felt. 

2. Distention of the Vesical Walls.— This may be attained by ele- 
vating the bladder region so that the abdominal contents may drop 
towards the diaphragm. In this position, a vacuum is formed in the 
lesser pelvis; the hypogastrium is retracted, causing this vacuum. 
Therefore when an empty tube is inserted into the bladder, the air 
rushes in and fills it completely, thus causing dilatation of the viscus. 

This method is preferable to that of injecting air into the vesical 
cavity under pressure. The latter method, recommended for more 
than ten years by Nitze, has been completely abandoned since then 
by its author, on account of its nianx disadvantages.^ 

In order to elevate the bladder and cause its distention, two pro- 
cedures may be adopted: 

Kelly and other American surgeons place the patient in the genu- 
pectoral position; but this position is fatiguing to the patient and un- 
comfortable for the surgeon. It seems more practical to place the 
woman in the Trendelenlmrg position, for example, and supporting 
her shoulders. The idea of using shoulder props to sustain the weight 
of the body and permitting a comfortable gynecologic examination in 
the inclined position, was first suggested by Jayle, in 1897.' It is but 
an act of justice to term this position the "inclined position of Jayle." 

It may be said that the vesical wall is readily distended when the 
bladder is normal or not seriously diseased, or when the patient is 
not too obese; but when the fundus is inflamed and the vesical walls 
are contracted, the distention is far from satisfactory. "When the cysto- 



220 



CYSTOSCOPY AND URETHROSCOPY 



scope is properly handled, however, the entire mucosa can be examined. 

Satisfactory distention of the bladder is obtained by having the 

patient breathe Avith the chest only, and not with the abdomen; tliat is, 




Fig. 138. — Genupectoral position adopted by Kelly for endoscopic examination in the male (Kelly). 

to have the patient use the superior costal muscles and not the dia- 
phragm. During the costal inspiration, the abdomen retracts and 
favors the dilatation of the bladder. On the other hand, during dia- 




Fig. 139. — Method of introduction of Kelly's endoscopic tube in the male (Kelly). 



phragmatic inspiration, the intestinal mass is pushed downward and 
actually prevents vesical distention. Perfect dilatation can, there- 



miM'U'T vision: (•^■sTos('OPv 



221 



fore, be seciircil !)y iiislnidini;,' pnllfiils as to 1li<'ii- i-('S|)ira1 ion before 
tlio cxniniiiniioii. 




Fig. 140. — 111 tlie inclined position, the intestinal mass is drawn toward the diaphragm in the direction oi 
the arrow B, but not backward because of the presence of the vertebral column. 

In certain very obese joatients even under chloroform anesthesia, 
vesical distention is obtained only nnder great difficulty in the reclin- 




Fig. 141. — In the genui)ectoral position, the intestinal mass is not only drawn toward the diaphragm 
in the direction of the arrow B, but also forward in the direction of the arrow A. The free space indi- 
cated by the double arrow < > is much greater in this position than in the preceding one. 



ing position because ol' llie abdoiniiial i)leibora. In sucli cases, the 
genupectoral position reconnnended by Kelly may liave to be adopted. 



222 



CYSTOSCOPY AXD rEETHROSCOPY 



It must l)e admitted in this connection, tliat the dilatation of tlie blad- 
der is greater in this position than in the reclining position (Figs. 138- 
139). 

In the genupectoral position, the intestinal mass has two direc- 
tions of movement which permit the dilatation of, the bladder, — one for- 
ward, at the expense of the supple abdominal Avail and Avithont opiDO- 
sition, and the other npAvard, in the direction of the diaphragm. In 
the inclined jDosition, on the other hand, the intestinal mass has but 
one Avay of escape, i. e., toward the diaphragm. The vertebral colnmn 
as comjDared Avitli the abdominal AYall, is iixed in its position, and can 




Fig. 142. — First step in the examination of the bladder in the genupectoral position in the male. 
The cystoscopic tube is fiist introduced with its elbowed obturator, wh'-le the patient is in the^ horizon- 
tal position; this having been done, the patient is asked to turn over gentlv and place himself in the genu- 
pectoral position (see Fig. 143). 



not undergo any displacement. We may therefore saj that the genu- 
pectoral jDosition furnishes a more satisfactor}^ distention of the blad- 
der and must be resorted to Avhen the inclined position for one reason or 
another, is not satisfactory. 

EA^en in the male, Avhen direct Adsion cystoscopy is indicated, but 
Avlien the bladder can not be couA^eniently dilated in the inclined posi- 
tion because of extreme embonjDoint, it may be Avell to use the genupec- 
toral position. The latter seems at iirst, quite difficult to attain, but it 
can be done easil}^ if Ave proceed methodically. The cystoscope is intro- 
duced Avith the patient on his back (Fig. 112) ; then, the surgeon hold- 



DIIM'XT VISION CVSTOSCOPV Tl.i 

iiiU' the ins1 niiiiciil /';/ siln, tlic jjaliciil is i-c(|U('sted to turn over very 
sl()\vl\-, placiii.u- liiiiiscir liiially in the ,u('iiiij)i'('1()i';\l ])ositioii, as slio^vii in 

Ill one iiislaiK'c, this inaiiciuc!' was especially nselul to one of my 
patients, '^riic !< 11 kidney had l)een removed for tulx'i-eidous pyonepliro- 
sis. After tiu' ()])eration, vesical lesions j^ersisted with symptoms of 
marked cystitis. Indirect cystoscopy showed two plaques of tul)er- 
culous cystitis (•ir('uiiiscril)ed clearly on the upper l)hidder wall. I 
placed liiiii in tlie ,i;('iin]X'ctoi-al position and ol)taine(l an excellent dila- 
tation of the hladder. AVitli niy direct vision cystoscope I saw the in- 
flammatory i)]aques on the upjier wall (Plate XVI, Figs. 2 and o), and 




Fig. 143. — Local treatment of cystitis in the male, ir. the genupectoral position. 

was enahled to make direct applications of lactic acid solution which 
resulted in a decided improvement. 

KEFEEEITCES 

iNitzo: Lehrbuch der Kystocopie, 1889, pp. SO, 81. 

2Jayle: Prcsse mod., June 22, 1808, p. 336; also Feb. 15, l>;!i<i. Xo. l.*"., p. 79; Rev. de s.vnec. 
et do chir. abd., April 10, 1899, No. 2, p. 314. 



o. Aspiration of the Urine. — The constant secretion of urine 
through llio ureters makes it iiiqiossihle to ohtaiii a dry mucosa for a 
proper examination. The urinary secretion takes place so rpuckly that 
it is difficult to make an examination between the applications of the 
swal). It is tlierefore necessary to establish continuous aspiration of the 
urine. Kelly lias dexised an as])irator consisting of a rubber bulb which 
cominunicates hy means of a rulihei- tube with a small silver ])erforated 



224 



CYSTOSCOPY AXD URETHROSCOPY 



ball. This aspirator is introduced into the cystoscopic tube, thus fur- 
ther narrowing the lumen of the tube and also necessitating the pres- 
ence of an assistant. «>► 

In the belief that such a sjDecial instrument is not necessary, I have 




Fig. 144. — Water horn (faucet). 

constructed a small gutter or trough in the inferior Avail of my new 
tube, through Avliich the aspiration of the urine takes place. The. ori- 
fice of this channel reaches doA\Ti to the vesical end of the cystoscope; 
externalh^ it ends in a metallic tube to which is attached a rubber tube 
(Fig. 145). The latter empties into a closed jar controlled by two 




Fig. 145. — I.,uj's' female cystoscope, with its straight obturator. 

stop cocks in which a vacuum can be created. The vacuum can be 
established by a Potain aspirator, but this is not to be recommended 
because the vacuum thus created is not sufficient for the purpose. It 
is much more practical and even essential to use a Avater horn attached 
to a faucet (Fig. 144). On opening the faucet a A^acuum is produced in 




Fig. 146. — L,uys' male cystoscope, with its elbowed obturator. 



the jar and the urine is thus aspirated. The manipulation is A^ery sim- 
ple; asjDiration is rapid and i^erfect, cleansing the mucosa not only of 
urine, but also of any mucus or blood clots Avhicli might be j)resent. 



DIRECT VISION' cssroscopv 



225 



This coiislniil cNacualioii of iiriiic is iii(lis|i('iis;il)l(' to clc-ir \isioii and 
tlie exatniiialioii can tliiis he iiiadf witlioiil inlcri'iiplio!!. 

Tlie water pressure in Ww. iaucet should l)e of sufficient strenr;,th; 
and the Tu])l)er tuhin.i;' shouhl l)e sufficiently firm so that it Avill not col- 
lapse when the \acuuni is estahlishcd in the jar. The latter has a two- 
hi'aiiched glass luhc Icadiiiu,' into it. To one is attach('(l a ruWhci- luhe 
which is coiniected with the water faucet, and to the other is connected 
the tube which receives the urine from the bladder thi'ouah the cysto- 
seope. 

4. Magnification of the Image. — ^lagnification is obtained by the ad- 
dition of a mova])le lens having a focal length corresponding to the 
length of the cystoscopic tube. This lens may be applied at the external 




Fig. 147. — Uandle of the direct vision cystoscope, with its movable lens; it is the same as the handle of 

the urethroscope. 

orifice of the tube without in any way interfering with the introduction 
of instruments; when not in nse, it can be rotateti out of the way (Fig. 
147). 



DESCRIPTION OF THE DIRECT VISION CYSTOSCOPE (LUYS) 

This instrument consists essentially of a metallic tube, 18 cm. long 
for the male, and 10 cm. long for the female. I liave adopted this length 
for the female cystoscope, allowing four centimeters for the vulvar 
distance, two centimeters for the urethra, and the remaining four cen- 
timeters for llic bhidder proper. The caliber of tlie lube selected varies 
according to the caliber of the uretln-a, which, according to Kelly, 
varies from six millimeters (minimum) to twenty millimeters (maxi- 
nmm). According to Simon, the maximuni (lilalability of tlie female 
urethra is a little more than 29 centimeters. 

It is usuallv sufficient to use a Xo. 2f) Charriere tube, but if the 



226 



CYSTOSCOPY AND UEETHBOSCOPY 



urethra is normal, a larger tube may be used, as it will provide a mucli 
larger field of vision. As often as circumstances permit, I i^se a 29.5 
Cliarriere tube in either sex. 

As previously mentioned, there is a ver}^ minute channel or gut- 




Fig. 148. — Collin's group of batteries. 

ter in the floor of the urethroscope ; this does not impinge on the lumen 
of the tube. It is connected with the vacuum jar by means of a rubber 
tube. There is another little gutter on the upi^er wall, parallel Avitli 




Fig. 149. — I<uys' direct vision cystoscope for the female. 

the low^er, for the lami^ carrier, so as not to obstruct the tube's lumen. 

The tube is introduced with the aid of a straight obturator (Fig. 

145) for the female cystoscope, and an elbowed obturator for the male 



DESCr.lPTloX Ol' l)ll;i:('T VISlOX CVSTOSCOPH 



227 



(Fi.i;'. ^4(')). ''I'lic ('11)()\v(m1 porlion projccls hcyotid llic liilx' into Hie 
])la<l(l('i' I'oi- ilircc ('(MiliiiK'tcrs, aiid can he sli'ai^^lilciKMl oi- IxmiI l)y 
iiicatis of a sci'cw. 'I'lic bend in ilic oMurator facilitates llic inti'oduc- 
Hoii of tlic iiisti-uiiHMit into llic bladdci'. As soon as it lias l)0('n intro- 
duced, the obturator is straiii,-litene(l and witlidi-awii from 1lic bladder, 
llluniination is furnished by a miniature electric lamp, described above 
(page 40). It is extremely brilliant considering its small size, and ab- 
solutely "cold," especially when ne^^^ Unfortunately, as the lamps 
groAV old, they require a greater current and consequently produce 
more heat, which constitutes a decided disadvantage. It is advisal)lo 




■'//■■ ' I 



Fig. 150. — I,uys' direct vision cystoscope for the male. 



in actual practice, to use only such lamj)s as are absolutely cold, re- 
jecting those Avliich show evidences of getting warm. 

The lamjD is carried on a long stem attached to the handle of the 
cystoscope. The latter is provided with an interrupter and receives 
the conducting wires of the electric current. It carries in addition, 
a demountable magnifying lens, situated in a movable frame. Its 
focal length corresponds to the length of the tube. The lens, as already 
mentioned (page 45), may l)e constructed with an aperture in its cen- 
ter, thus making it unnecessary to move it aside when making local 
applications to the vesical mucosa. 

The handle is firmly fastened to the tube l)y means of a screw. 
The source of the electricity varies according to the i)lace where the 
instrument is used. Undoubtedly the street current is the most de- 
sirable and practical, but the high Noltage must be reduced by the em- 
ployment of a rheostat (Figs. 4G and 47). 



PLATE XIV 

Fig. 1. — Chronic cystitis. Aspect of the fundus resembling grains of sand. 
In front, the interureteral ligament is seen; posteriorly, on another 
plane, chronic cystitis is visilile in the form of grains of sand, and 
still further back, healthy mucosa. 

Fig. 2. — Vesical herpes. The right ureteral orifice is seen, and near it, 
disseminated herpetic plaques, transparent, and resembling bubbles. 




Fis. 1. 




TICCIINIC ()!•■ DIKKCT VISION (•^■ST()S(:()PY 



1220 



TECHNIC OF DIRECT VISION CYSTOSCOPY 

Preparation of the Instruments. — Th^i iii.slruinoiil.s sliould Ix; steril- 
ized. The eyslos('()])i(' luhe and its obturator can l)e l)oiled in water; 
tlie lamps are sterilized in a trioxynietliylene (paraform, formalin) 
sterilizer. The vacuum apparatus is tested to see that it works prop- 



Fig. 151. — Tampon of cotton niounteil on a wooden apjilicator. 

erl\-; likewise the lamps and the electric current. AYooden applicators 
capped with sterile cotton should be within easy reach on a tahle (Fig. 
151). 

Preparation of the Patient. — The patient is undressed except for 
his shirts. The bladder is washed with a catheter, syringe or irrigator, 




Fig. 152. — Tabic specially Ijuill accordi'.'g to my directions for urinary examination, horizontal iiosition. 

until llie washings come out (piite eleai-; llie bladder is now emi)tied 
comjjletely. The jiatient is jilaced in the ])artial Trendelenburg posi- 
tion, the buttocks resting on the edge of the table. Adjustable shoulder 
supports help to maintain the patient in the i^roper position. The feet 
rest in the stirrups witli the legs ^^('ll separated. For e.Kainiuation of 
the bladder fundus or for ealhelerizalioii of the ureters, the buttocks 



230 



CYSTOSCOPY AND URETHROSCOPY 



should not be elevated too much. On the other hand, the roof of the 
bladder is better inspected Avlien the thighs are well elevate^. The 
head may rest on a little j)illow. 

In acute painful cystitis or in sensitive patients, a local anesthetic 
should be employed. Ten to 20 c.c. of a sterile 1 per cent solution of 
stovaine may be used. Bransford Lewis, of St. Louis, deposits little 
tablets containing 5 to 10 per cent of cocaine into the posterior urethra 
by means of his tablet depositor. According to this author, anesthesia 




Fig. 153. — Table specially built according to my directions for examination with direct vision cystoscope. 

of the bladder can be jDroduced more easily by this ingenious method 
than by any other. 

Half an hour before the examination, a solution containing twelve 
drops of laudanum and one or two grams of antipyrin may be de- 
posited in the bladder for anesthesia. In extremely painful cases, an- 
esthesia may be produced by the subcutaneous injection of scopolamine, 
according to the technic described by Terrier ;^ also by an injection of 
morphine, or in extreme cases, through the use of a general anesthetic. 



REEEREI^CE 

iTenicr: Bull, de Soc. de Chir., 1905, p. 347. 



TICCIIXIC Ol' IHUKC'I' VIS I OX CYSTOSCOPY _.>l 

Operative Technic 

Introduction of the Cystoscope in the Female. — If a i-atlicr lai-ft'c 
eysloscopic liihc has Ix'cii clioscii, ;i Xo. 2!)..") For cxaiiipN^ it is well to 
dilate tlic urcllii'a lii'sl, cillici- witli Kcilly's meatus dilator or l)\' ilio 
l^assage of Jlegar's rounds, No.s. 6, 7, 8, and 1). This facilitates tlie in- 
troduction of the cystoscopic tube. If the meatus is somewliat nari'ow 
and sensitive, it is well to insert into the urethra, l)efore dilatation, a 
cotton tani])()n soaked in a 5 or 10 per cent solution of stovn.ine; this 
is liii;lilv recoiiuueuded hv Kelly, and f^'ives excellent results. 




Fig. 154. — Examination of the bladder with the direct vision cystoscope. 

The cystoscope having Ijeen sterilized and lubricated with sterile 
glycerin, is gently inserted into the bladder. The obturator is with- 
drawn and when the table is elevated, it is seen that the bladder be- 
comes filled with aii'. 

In the Male: In llie male, it is al)solutely necessary to have a canal 
free from stricture, and stretched in advance l)y the passage of sounds 
up to 28-29, if possible. If this jn-ecaution has been taken, the intro- 
duction of the cystoscopic lube ])i-("S(Mits no (iilliculties. The instrument 
is inti'oduced into the hiaddcr with the elbowed obturator. The screw 
controlling the handle is released, thus straightening the obturator, and 



^32 



CYSTOSCOPY AND URETHROSCOPY 



tlie latter is withdrawn from tlie tube. The operative teclmic is now 
tlie same in both sexes. 

The cystoscope having been inserted, the aspirator is connected, 
so that the bladder will be kept dry thronghout the examination. Oc- 
casionally Avhen the bladder is not well dilated, the mncosa may pro- 
trude into the interior of the tube. It is then necessary to interrupt 
the aspiration until a little fluid has accumulated in the bladder. The 
handle of the cystoscope is now fastened by a screw and the current 
turned on. 




Fig. 155. — K-xamination of the bladder. 






Exact position of the direct vision cystoscope in the female. 



The bladder is seen splendidly illuminated, so that every detail 
can be recognized. The vesical extremity of the cystoscopic tube moves 
freely in the bladder and can be easily manipulated in all directions, 
because of the distention brought about by the inclined position. 

Examination of the bladder floor is quite simple. By raising the 
handle of the instrument, the vesical end is depressed correspond- 
ingly, thus bringing the trigone within view easily. The roof is ex- 
amined by lowering the handle of the cystoscope and thus elevating- 
its vesical extremity. It is advisable to make gentle pressure on the 
abdominal wall over the bladder; the entire bladder roof then comes 
into view in the cystoscoiDic tube, and no jDortion of the vesical mucosa 
can escape observation. 



'i'i':cii NIC oi' i)ii;i:ci' \ isiox cn'stoscoim' 



233 



Ai'.X()i;.MAi. Cases 

III (liiccl \isi()ii cysioscopy, pdl)' <lir(iciiU ics iii;i\' he ciiccjiiiitcrcd, 
]).-ni iciilarly li>' ;i iioxicc, llic two inosl iinptniaiil liciiii;' llic ("ollowjiig: 

1. llic hhuhlcf (Iocs iiol dildlc I iillij undar the influence of the in- 
rliiicfl po.^lliou. This mn\' he due to several causes: (a) The patient 




I'ig. 156. — If the bladder does not dilate well in the inelined position, an assistant elevates the abdom- 
inal wall, thns facilitating the stretehing of the bladder. 

may he too stout, and tlie al)doininal fat may prevent tlie bladder from 
distending itself and tlms becoming filled Avitli air. Tt is tlien neees- 
sarj'' to still fui'tlier elevate tlie pelvis. W'lieii Ihe iiicliiied iio^ilion lias 
been ])uslie(l to its limil, and if the hhidder still does not distend it- 
self, the followiiiu' expedient iiia>- he employed, es])eeially when the 
abdominal wall is llahhy: An assistant grasps the abdominal wall as 



234 CYSTOSCOPY AND URETHROSCOPY 

near tlie pubis as jDossible, with both hands, raising up as much of the 
wall as he can seize (Fig. 156). This maneuver will very often succeed 
in causing distention of the bladder and a jDerfect view of tlie entire 
vesical cavity is thus obtained. If, however, the result is still unsat- 
isfactory, the genui^ectoral jDosture must be resorted to. (b) The pa- 
tient may be thin, but resists and contracts the abdominal muscles 
spasmodically. This is because the patient is nervous, and requires 
a local anesthetic before relaxation is secured. 

2. Tlie vesical mucosa may bleed profusely. This renders a clear 
view extremely difficult and nothing but blood can be seen. The ac- 
tion of the aspirator is insufficient to take up a large quantity of blood, 
and even if it took jxp all the fresh bleeding, it would still be unable to 
remove the coat of blood which covers the fungosities in the bladder. 
In such cases it is necessary to swab the mucosa with little tampons of 
dry cotton. Occasionally however, the mere contact of these swabs 
actually increases the bleeding of the mucosa. The only thing to do is 
to use a 1 :1000 solution of adrenalin. Tampons soaked Avith this solu- 
tion are brought into contact with the bleeding points and the hemor- 
rhage ceases. 

ADVANTAGES OF DIRECT VISION CYSTOSCOPY 
IN EXAMINATION OF THE BLADDER 

The direct examination of the vesical mucosa by the simj)le cysto- 
scopic tube offers many advantages over the indirect (iDrismatic) 
method. In the normal bladder, the two i3rincij)al advantages are the 
following : 

1. The Direct View. — With direct vision the various regions exam- 
ined are seen just as they really are, in their normal position, form, 
and situation, and are not deformed in any manner. The personal in- 
terpretation does not enter into consideration and no matter how inex- 
perienced in cystoscopy the observers may be, they all see the pictures 
alike, because the image is not deformed or inverted. This is a de- 
cided advantage, especially in determining the volume of a stone or of 
a vesical tumor. In fact, in order to see well with the indirect cysto- 
scope, it is necessary to keep the instrument at a certain distance from 
the object. Inasmuch as it is difficult to say what this distance should 
be, even a well-practiced eye may make serious errors in determining 
the actual size of foreign bodies in the bladder. 

In making a full view examination, the direct vision cystoscope 
also has a decided advantage over the indirect. By inclining the tube 
so that its long axis is almost parallel with the surface of the mucosa 



ADVANTA(JES OF DIItECT VISION CYSTOSCOPY 235 

to he cxainiiKMl, a scries uT cliau^i'S of the iiiiicosa can l)c ^ccii in pro- 
lilc which woiihl escape iinol)servo(l when the same mucosa is looked 
al in Tull \ie\v. I ha\<' thus heen enal»hMl to ohserve and make sketclies 
ill miiuerous cases ol* cliroiiic cystitis, of alterations consisting- of little 
elevations in the form of grains of sand wliicli can not be seen well 
with the indirect cystoscope. 

2. Normal Coloring of the Mucosa. — Tlie necessily of liilini;' the 
l)la(i(U'r witli water or air, in oi'der to obtain a good view in indirect 
cystosco])y, causes a certain amount of distention which in tuiii, pro- 
duces a condition of anemia. The real color of the nuicosa is therefore 
not seen. On the other hand, in direct vision cystoscopy, the hla<lder 
is distended without force and the natural tints of the nmcosa are seen 
just as they are in reality. 

3. Possibility of Examination in Contracted Bladder.— The di- 
rect vision cystoscope permits the examination of inflamed l)ladders 
which have not a sufficiently large capacity to permit their distention 
by the quantity of fluid required for indirect cystoscopy. It is well 
known that ]:)rismatic (indirect) cystoscopy is well nigh impossil)le 
when the vesical capacity is less than 60 c.c, and gives results Avhich 
are practically nil. Such instances are not at all rare; especially is 
this true when the ureters are to be eatheterized. I shall again con- 
sider this later on. 

4. Possibility of Examination in Hematuria and Pyuria.— In hema- 
turia and pyuria, when examination is almost impossible in spite of the 
most copious irrigations, direct vision cystoscopy has a distinct ad- 
vantage over the indirect method; only by this method, can we obtain 
the necessary and precise information in cases of profuse hemorrhage 
which would obstruct the field of vision in the indirect vision cysto- 
scope. In this manner, errors which are as considerable as they are 
to be regretted, can be avoided. 

An especially interesting case observed by me, is that of a woman 
aged forty years, whom I treated in 1907. She was a patient of Uoutier, 
who had referred her to me because of hematuria, and he wanted my 
cystoscopic opinion. Another specialist, who was previously consulted, 
had declared after an indirect cystoscopy, that the patient did not have 
a tumor of the bhuhU'r, but that slie ha<l a cyst in 1lie lower extrem- 
ity of the left ureter! AVIieii 1 examined her, she liad well-marked 
henuituria. As soon as the indirect cystoscope was inserted into the 
bladder, whirlpools of blood prevented distinct vision and made the 
examination impossible. I then used my direct cystoscope and was 
enabled to make a ]iositive diagnosis of a large tumor of the bladder 



236 CYSTOSCOPY AND URETHROSCOPY 

situated in the left lateral portion of the fundus. In view of this diag- 
nosis, Eoutier had his patient enter the sanitarium two days Igter. 

On opening the bladder, a tumor the size of a pigeon's egg Avas 
removed, and the histologic examination, made in the laboratory of 
Necker by Herrenschmidt, showed that the growth Avas a hbroma.* 

5. Possibility of Examination in Cases of Perforation or Vaginal 
Fistula. — The direct vision cystoscope is the only instrument for the 
examination of a bladder with a fistula; such for example, as a vesico- 
vaginal fistula. In these cases, it is manifestly impossible to distend 
the bladder Avith a fluid Avliich it can not hold, and the only method to 
be employed is certainly direct Adsion cystoscopy. 

It is superfluous to insist on the importance of the exact knoA\d- 
edge of the seat of the A^esical ]3erforation in A^esicoA^aginal fistula. 
With the aid of ni}^ direct Adsion cystoscope, a probe can be introduced 
into the fistula Avliich penetrates the A^agina and indicates the direction 
of the fistula in the clearest manner. The serAdces AAdiich this method 
may render in such a case, are Avell sIioaa^u by the tAvo folloAving ob- 
serA^ations by Ferron:^ 

"Ferron examined a patient Avith a A^esicoA^aginal fistula. A probe 
AA^^as introduced into the fistula through the A^agina; this Avas folloAved 
by direct Adsion cystoscopy. It shoAved that the fistulous orifice w^as 
very near the ureteral orifice. On operation, the fistula Avas sutured, 
at the same time avoiding closure of the ureteral meatus. 

''In another case, a mistake in diagnosis Avas rectified by direct 
vision cystoscopy. A Avoman liaAdng undergone total hysterectomy 
was emitting urine through the A^agina. The clinical diagnosis Avas 
vesicovaginal fistula. Then Ferron employed direct vision cystoscopy; 
the bladder seemed perfectly normal, and A^d^le catheterization of the 
left ureter Avas easy and produced urine, it Avas impossible to pass even 
a filiform into the right ureteral orifice. The diagnosis Avas tlierefore 
changed to ureteroA^aginal fistula." 

REFEEEI^CE 
iFerron: lu These de Chardon, la Cystoscopie a A-ision diiecte. Bordeaux, 1912, -p- 47. 

6. Possibility of Examination in Urethrovesicovaginal Fistula.^ — 

If A'^esicoA^aginal fistula? are not relatiA^ely rare in Avomen, that can not 
be said to ])e true of cases Avhicli are complicated Avith another com- 
munication betAveen the bladder and the urethra, in the form of an 
abnormal channel j)assing outside of the A^esical neck from the blad- 

*The specimen is to be found in our private collection. 



ADVANTACKS OF DIKKCT VISION CYSTOSCOPY 



237 



(Icf to lln' ])()sl('ri()f |)()iil()ii of llic iircllira. hi siidi a case, iiicoii- 
liiiciicc of urine scciiis lo proceed IVoiii 1!ie \-esi('o\-a,i;'iiial li-liila alone, 
l)ul ilie oilier vesi('()])araiirel liial canal is none 1lie less an intereslin.L!; 





Fig. 157. — N'esicovaginal fistula. A catheter is introduced into the urethra; the opening of the fistula is 

seen a little below and to the right. 

anatomieopatliologic complication Avliicli mnst ho takcMi into consider- 
ation. 

These nrellirovesicova.ninal lislula' liave ])cen ol)ser\-e(l Imt rarely, 
and the cases oi* this kind met Avith in literature do not reseml)le the 
one al)out to be descril)ed, for the urethrocystoscopic investigations 



238 



CYSTOSCOPY AND ITRETHEOSCOPY 



which coukl reveal them ^ve^e not in current medical practice at that 
time. Mv direct vision cystoscope gives a clear view of the neck of the 
bladder quite as well on the vesical side as on the urethral, and thereby 
facilitates the investigations considerably/ 




Fig. 158.-Determining the exact position of the orifice of a vesicovaginal fistula by means of di- 
rect vision cystoscopy. A grooved director inserted into the fistula marks the orifice of the fistula m tne 
bladder. 

Verneuil has called attention to this subject/^ and has reported sev- 
eral cases of fistula joining the neck of the bladder with the urethra; 
he termed them '^irethrovesicovaginal fistula?." He distinguished 
several groups: 



ADVAKTAdES Ol' DinKCT VISIOX CYSTOSCOPY 



239 



1. \'('i'y loiii;' lisliihi', nCrccl iiii;- llic neck ol' llic l)l;iil<l('r and o!' tlic 
ui'dliia coiisidcrahlx', and sliowiiii;' one lar,i;'(' ()])('nin;:,' l)()i-d<'f(Ml hy llio 
])liul<kn' miil llie I'eiiuiaiit of tlie urelliia. 

2. Fistultc situated low down, A\itli a modi fixation of the ure- 
tliral patli or caliber:* Verneuil tlioii;j,ld lliat many cases reported as 
obliteration of the canal, are rather deviations, and tlial ol)lil('iation is 
very rare. ITe cites two cases. 

3. Fistnhi^ situated low down, in wliich a continuous incontinence 
simulated a complete destruction of llic urethra and its sphincter: 
Tavernier and Stephani have observed also a vesicovaginal fistula 
which involved the neck of the bladder and the urethra; they suc- 
ceeded in bringing about a perfect cure, with complete continence." 




Fig. 159. — Diagram showing the arrangement of the ureterovesicovaginal fistula. 

A monograph Juis recently appeared on this sul)ject, l)y Piontik, 
of Pesia {Ueber Blasen-Cervixfisteln, Charlottenlnirg, 1909). The case 
which is the basis of this report, is the following: 

Mme. W. L., aftcd twenty-nine, was sent on Felnuary 3, 1911, to the Broca Hospital, 
in the service of Pozzi, complaining of constant enuresis. Six months previously she had 
Ijcen delivered of a child with forceps, at the Maternite; half an hour later, incontinence set 
in; the condition was unchanged whether she was lying in bed or up and about. 

She went first to tlie Beaujou Hospital, where she was operated upon on October 12, 
1910, but without any iiii|iiiivemcnt whatever. On entering Broca Hospital, she presented a 
marked erytlicma on the inner surface of tlie thighs, due to the constant involuntary flow 
of urine. 

On examinatifin it w;is found thnt the vesical cajiacity was about 200 c.c. Al)Ove 



PLATE XV 

Fig. 1. — Vesical leucoplalia. This condition, observed during the course of 
a very marked cystitis, is characterized by the pale plaques of cystitis 
which contrast Tvitli the strikingly inflammatory red of the rest of the 
bladder. 

Fig. 2. — Chronic cystitis. Mosaic aspect. 




Fig. 1. 




Fig. 2. 

PLATE XV 



ADVANTACKS Ol' DIIIIUT \ISI()N CVSTOSCOPY 241 

this (|ii,'iiit ity (lie injci-lcil lliii.l cscnijn! Iiv llir v;i;iiii;i. I ' i d li i;il rii(|(,sc(i]iy showed lliiit 
I he ciiiiiil neck WHS ilisliiilcil. A I11I1C (if my diicct vision cysloscopo wsis (djstniftpd ;it tiic 
l.hiildci neck :iiid cnnld mil pciiil nil c riiilhrr. it wris imjiossililp to introducn tlu! iiislrunu-nt 
ildn lllr liliiddci' unless 1 lie exticiiiily n I' the i list liniieiil \v;is luriied olili(|uely 1111(1 rlilTCtcd 
under cniitrnl (d' the eye. 'I'he ('iHi()Sco|iic exaiiii n;it ioii slioweii lliat on tlic rigiit side of the 
lihidder neck ;in 1 exierniii (i> it, thero was a distinct oiififp witli edematous edges. A ureteral 
ciitiuMor No. (i, was iidroduced into this orifice; it ])assc'd tlio right lateral portion of the 
vesical neck, rounded it and entered the bladder after a passage of from two or three centi- 
meters (Plate XIII, Fig. (i). This was therefore a real urethral fistula. Examination of 
the ureteral orifices revealed that they were normal, normally locatoil and could be easily 
catheterized. 

In Sims' ]iosition with the speculum, a vesicovaginal fistula about the size of a franc 
\2'> cent piece I was seen at the neck (if llie bladder and alniosl luiichin- il. Tliif; fistula 
took on the apjieaiance id' a cleft, the anterior edge of the orifice overlapping the posterior. 

To sum u[i then, there existed in the vesicovaginal partition a fistulous passage, bi- 
furcated from a single orifice: One passage, a large one, extended from the bladder to the 
vagina; a second passage, smaller, passed from the bladder to the urethra, and extended 
around and outside of the bladder neck (see Fig. 159). The incontinence seemed to be 
(iuc to the first of these passages, and was made the object of surgical intervention. The 
radical cure of the vesicovaginal fistula was effected by operation, on March 4, 1911, by 
Pozzi. 

The edges of the fistula were transfixed by retention sutures of silver wire, the fistula 
well exposed and the edges excised. Excision was difficult because of the proximity of the 
jieck of the bladder. To avoid traction on the upper edge, a large transverse incision was 
made in front of the neck of the uterus, which allowed the union of the edge to the fistula 
and thus gave a large raw surface. The fistula was first obliterated with chromic gut. The 
closure of the fistula was then completed by some deep silver sutures which passed into the 
uterine neck. Finally, perfect apposition of the wound was secured hx superficial silver 
sutures. A permanent catheter was passed into the Ijladder. 

The postoperative history was without incident. On March 17 the sutures were re- 
moved; on March 24 the catheter was withdrawn and patient sat up. The operative result 
was perfect, for she regained complete urinary control, whether reclining or up and about. 

On March 31, 1911, endoscopy showed that the above described anatomic conditions at 
the bladder neck remained unchanged. The same orifice on the right side of the bladder 
neck still permitted the introduction of a ureteral catheter which passed easily into the 
bladder. But this did not at all interfere with the bladder function, the bladder remaining 
(inite water-tight, and urination being performed under normal conditions which required 
no further therapeutic interference. The patient left tlie hosjiital, and when seen seven 
itKMiths later (October,. 1911) she was in excellent condition. 

7. Possibility of Examination with Pregnancy or Abdominal Tu- 
mors. — It is a well-establisliod fact tliat to ol)tain a distinct view witli 
tlie indirect vision cystoscoi^e, it is necessary to keep the instnniient at 
a certain distance from the object to be examined. Now, avIicii the 
hUidder is compressed through pregnancy or because of a tumor near 
the bhidder, this mass makes it impossible to maintain the cystoscopic 
prism at a sufHcicMit distance from the vesical mucosa. Tliis disadvan- 
tage docs not exist in dii-ect \isi()n cyst<)S('()p^^ Ix'cause tlie iiist ruiiieiit 
can he hfought to the wvy wall of the hhuhler, and aUows the smalh\st 
(h'tail to he studied. Isxaitiiiiat ion of the hhuhh'i' in ])regnancy Avitli 



242 CYSTOSCOPY ajstd urethroscopy 

the direct vision cystoscope, lias been studied in collaboration with 
Bar; a report of this work is published further on (see page ^48). 

8. Extraction of Foreign Bodies. — Extraction of foreign bodies is 
extremely easy with the direct vision cystoscope ; this subject will also 
be thoroughly discussed later on. 

9. Treatment of Cystitis. — The treatment of cystitis with the di- 
rect vision cystoscope gives results that are absolutely remarkable,- 
and will be discussed at greater length. 

10. Treatment of Bladder Tumors.— The treatment of bladder tu- 
mors with the direct vision cystoscope produces radical cures. This 
subject will likewise be discussed in subsequent pages. 

RErEEEISrCES 

iLuys: Eev. de gynec. et de chir. abd., March, 1912, No. 3. 

-Luys: ExiDloratiou de I'appareil urinaire, Paris, Massou, 1909, ed. 2, p. 217. 

2Verneuil: Chirurgie rex^aratriee, p. 932. 

^Verueuil: Bull, et mem. Soe. de chir. de Paris, 1875, p. 322. 

^Tavernier aud Stephaui: Lyon med., Dec, 1909, p. 1023. 

OBJECTIONS TO DIRECT VISION CYSTOSCOPY 

1. Diminution in the Visual Field. — It is undeniably true that the 
visual field is much more restricted in direct vision cystoscojDy than in 
the indirect system. However, this reduction is more apparent than 
real. It is quite true that when the extremitj^ of the cystoscope is ap- 
plied directly to a point of the vesical mucosa, the observer's eye can 
not pass much beyond its limits. On the other hand, it is equally true 
that when the cystoscopic tube is kept at a certain distance from the 
surface to be examined, the visual field becomes much more extensive. 
In fact, the ease and rapidity with which the cystoscopic tube can be 
inanijDulated in the interior of the bladder, make i^ossible a thorough 
examination of the entire surface of the mucosa. Tuffter has well said 
in this connection, ''What one sees, one sees very clearly."^ 

2. Caliber of the Instruments. — The instruments employed in di- 
rect vision cystoscojoy are necessarily larger in caliber than those used 
in the indirect method. The size of the instruments used in the female 
is of little moment, owing to the ease with Avliich the female urethra 
can be dilated; in the male, however, the question of size of the instru- 
ment is of considerable importance. It may be well to remember how- 
ever, in this connection, that the difference in caliber between the cysto- 
scope for ureteral catheterization (25 Charriere) and my male cysto- 
scope (27.5 Charriere) though appreciable, is nevertheless not very 
considerable. 



r)i;.ii:(Ti()X.>^ To diiikct visiox cystoscopy 243 

I). Unfolding of the Vesical Wall. — As lias alicady ])oon stated, 
llic iiiiroldiii^' ol' llic N'csical wall 1 li foii.^li llic iiidiiKMl position some- 
times fails, in the ohcsc, particnlarly tJie maie, tlius maixiii;;' tlic lilad- 
der examination difticnlt and sometimes even impossible. 

This faulty retraction of the al)dominal wall is usually due to al)- 
dominal plethora, which prevents the bladder from filling up with air, 
in the inclined position. However, there is a method of overcoming 
tliis disadvantage, at least up to a certain point. It consists, as already 
stated (see page 233, Fig. 156) in having an assistant seize the ab- 
dominal wall above the pubis, Avith both hands, thus forming a large 
transverse fold, and exerting an upward pull; in this manner, the com- 
])]ete unfolding of the vesical wall is often obtained, esx)ecially in very 
stout women. 

The inclined position is likewise accepted very poorly at times 
by elderly patients, who are asthmatic or very stout. These conditions 
are evidently entirely unfavorable for direct vision cystoscopy and 
nmst be considered as a contraindication. 

REFERENCE 
iTufficr: Bull, et mem. Soc. de chir. de Paris, March 7, 1905. 

COMPARATIVE ROLE OF INDIRECT AND DIRECT 
VISION CYSTOSCOPY 

Having studied the comparative advantages and disadvantages of 
direct and indirect vision cystoscopy, it is well now to examine in de- 
tail the indications of each method, and the conditions under which 
one or the other is to be preferred. Above all, however, it should be 
stated that prismatic cystoscopy should not l)e set up in opposition to 
direct vision cystoscopy. Both methods are useful and each has its 
respective indications, and it were childish to attempt to estal)lish a 
rivalry between them. 

When the condition of the bladder ensemble is to be determined 
so that a diagnosis may be made, it is undeniably wise to begin with 
the indirect cystoscope. This instrument gives an extensive visual 
field, and a complete examination of the bladder can be made with it 
in a short time; and when the patient hapiDens to be large and stout, 
in whom the inclined position would be particularly uncomfortable, 
this instrument will l)e found pi-eferable l)y far. 

But on tlie otiier liaiid, when the presence of blood or ])us in too 
great a quantity renders it impossible to obtain a sufficiently trans- 
])arent medium even with the aid of the irrigating cystoscope, the di- 



244 CYSTOSCOPY AXD URETHROSCOPY 

rect vision cystoscope should be resorted to, and it will reveal every 
portion of tlie bladder despite severe bleeding or intense pjairia. In 
addition, donbtfnl jDoints will be cleared np and the real size of a tu- 
mor determined far better through the direct and immediate view than 
through the jDrism. 

If a vesical tumor or a foreign body is examined with both in- 
struments, the same impression can not be obtained with the indirect 
instrument as with the direct. It is a fact, that in order to see well 
with the indirect cystoscope it is necessary to keep at a certain dis- 
tance from the object to be observed; mau}^ bearings must be taken 
in order to be able to examine all around the tumor, to determine the 
distance and the volume of the tumor by this method. On the other 
hand, with the direct vision cystoscope, the object is seen directly as 
it reall}' is, and its exact size can be determined in the most x^recise 
manner. 

Moreover, in numerous instances, the indirect cystoscope leaves 
the oliserver in doubt as to the existence of a calculus in the bladder. 
Indeed, in chronic cystitis, the vesical wall ma^^ be altered to such an 
extent, that large masses of pus may accumulate in the fundus and 
simulate a stone perfectly. This error can never occur with the direct 
vision cystoscope, for it is an easy matter to introduce a metallic stylet 
into the cystoscopic tube and thus obtain the metallic contact which 
makes certain the diagnosis of vesical calculus. This maneuver is not 
possible with prismatic cystoscopy. [AVitli the most modern operative 
cystoscopes (indirect), it is just as simple a matter to introduce a sty- 
let up to the suspected stone, to obtain the metallic contact. This con- 
tact may often be obtained by the cystoscope itself coming in contact 
with the mass and eliciting the sensation the author refers to. — Editor.] 

Similarly, in studying certain inflammatory changes of tlie vesical 
wall, encountered in mild cystitis, much more numerous and clearer 
details can be seen with the direct instrument than with the indirect, 
because the tube of the direct cystoscope comes into direct contact with 
the wall itself, and thus brings the smallest details into view. jMoreover, 
by placing the tube in profile, a perfect view of the minutest elevations 
and of the slightest inflammations of the vesical wall can be obtained; 
these details are important and should never be neglected, for it is due 
to them and to the knowledge of their jDresence that exact indications 
for treatment can be secured. 

Still further, when both sides of the bladder neck are to be ex- 
amined, only the direct cystoscope should be employed. Indeed, while 
the indirect can furnish a detailed view of the vesical aspect of the 
bladder neck, it is absolutely incapable of furnishing any information 



ADVANTAGES OF DIIIECT VISION CYSTOSCOPY 245 

conccriiiiig lliu iirL'tliral side. (Jii llie oilier Jiaiul, llio din-ct vision 
cystoscope will give a perfect view of both aspects. With the cysto- 
scopic tul)e still inside of ilie i)ladder, its vesical extremity directed 
downward, the entire inferior wall of the bladder neck can be fully 
examined; directing tlie end of the tube upward, while tlie hand of an 
assistant makes downward pressure on the al)dominal wall above tlie 
pubis, the entire part of the bladder neck is thoroughly examined. 
The examination having been completed, on the bladder side, the cyst- 
oscope is then slowly withdrawn and the bottom of the tube is seen 
em]Dty at first, but gradually enshrouded as it Avere, from periphery to 
center, with the prostatic portion of the urethra (Plate X, Fig. 1). The 
urethra may now be minutely examined, since under these circum- 
stances, the cystoscope has practically become a urethroscope. 

Again, in the matter of local intervention, within the l)ladder, the 
direct vision instrument is to be preferred. Whether it be for the pur- 
pose of removing foreign bodies, cauterizing vesical tumors, or apply- 
ing local treatment to plaques of cystitis, it is best to have recourse to 
the direct vision cystoscope. 

And as for catheterization of the ureters, we shall not insist at 
the present moment, for Ave shall discuss the indications Avith one 
method or the other in a special chapter later on. NeA^ertheless Ave may 
maintain in advance the superiority of the direct instrument Avhich 
permits catheterization of the ureter directly, Avliile minimizing the 
chances of contaminating a health;/ kidney. The ureteral catheter 
passing directly from the sterilizer into the ureteral orifice, can not 
take up any infectious germs en route and thus contaminate the healthy 
kidney and ureter. 

Finally, as Ave shall noAv see, the direct vicAv cystoscope enjoys a 
Avell-marked superiority in the examination of the bladder during 
pregnancy. 

Note: The editor has recpiested Dr. William F. Braasch, Avho is 
one of the foremost American adA^ocates of direct cystoscopy, to state 
briefly the American vieAvpoint on this subject. His contribution 
foUoAvs: 

DIRECT CYSTOSCOPY 

By W. F. Bkaascii, M.D. 

''The direct cystoscope has been A'ariously employed in the cysto- 
scopic past. Foremost among the list of adherents to the direct method 
Ave find the name of HoAvard Kelly.^ His well-knoAvn methods need 
no further description, and today they are still widely employed. His 



246 CYSTOSCOPY AND URETHROSCOPY 

metliod has not, however, received universal acceptance for several 
reasons; namety, (1) the preponderance of lens sentiment^ (2) the 
awkward position and exposure of the patient, particularly if anes- 
thetic he given; (3) the inahility to employ the method in the male. 
The credit for presenting the first direct cystoscope of the modern 
type should be given to Bransford Lewis.- His instrument permitted 
the dorsal position use in the male and included catheterizing tubes.' 
Instead of relying on atmospheric pressure to distend the bladder, as 
in the Kelly method, he employed an air pump Avitli a retaining win- 
dow. Direct air cystoscopes, similar to that of Bransford I^ewis, ap- 
peared in rapid succession, Koch, Belfield, Snell, Eisner,^ Luys,* etc. 
These instruments did not receive widespread employment largely be- 
cause of the awkwardness and pain caused by air distention so em- 
ployed, and by the general recognition that Avater was the better bladder 
medium in cystoscopy. The emxDloyment of water in this type of air 
cystoscoi)e is responsible for its survival. The late M. C. Millet of the 
Mayo Clinic, was the first to demonstrate the value of this method. 
He was among the first to emi^loy the direct vieAV air cystoscope, and 
after finding the use of air so often unsatisfactory, substituted water 
for air. The use of water in the direct cystoscope embodied an en- 
tirely new principle. At first thought the idea of looking through a 
tube of water hardly seems practical. The water medium magnifies 
the field slightly and brings it out in clear relief, but does not distort 
the object observed. Furthermore, it is less painful than air in the 
bladder and is more easily controlled. Having briefly outlined the or- 
igin of the method we are emj)loying, I will discuss the comparative 
advantages of the lens instruments now used and the direct view water 
cystoscope. 

"The lens instrument offers the following advantages: 1. It gives 
a field of greater circumference. 2. It permits a clearer view of the 
anterior wall of the bladder in the male. 3. It offers a more detailed 
and magnified view of the bladder mucosa. 

"While it is true that the field of vision in an observation lens 
is greater than through a direct cystoscope, nevertheless with many 
catheterizing lenses the actual diameter of the field is not very much 
larger. Moreover, what one loses in circumference of the field is at 
least partially made up by the increase in perspective gained by di- 
rect inspection. Although the anterior bladder wall is easily viewed 
through an observation lens, still in the female it can be inspected quite 
as easily through the direct cystoscope. By partially emptying the 
bladder and by permitting the roof to sag down, but little escapes in- 
spection in the male bladder. With greatly liypertrophied prostates 



DiiU'Xrr cvsTo.scorv 247 

il iiin>' ()('(';isi()ii;ill\' liccoiiic diriiciill to iii^pcd th" aiilcrioi- lilaildcr wall. 
W'liilc llic (l('1<Mil(Ml and iiia,i;iiiri(Ml xicw oT llic Madder iiiiicosa and iiro- 
Icral incali ohlniiicd llii'()u,i;li a lens may occasional !>• Ix' of some ad- 
vaida^c, ju'vorllicdess llic picluic ohtaincd l)y tlic nnaidccl oye is a 
truer one and loses no data of jiraclical \alue. 

^'Tlie adv<iiila,i;'es of the direct \iew ai'c: 1. Its .-ihipler meelianisin. 
2. A clearer view of tlie iield in case of lieni()irlia,i;e. o. The field is 
]iatural, recjuiring no interpretation. 4. Use as iiretliroscope as Avell. 

"Tlie sini]:)ler niechanism of tlie direct cystoscope offers the fol- 
lowing- advantages: (a) It is less often damaged and in need of repair 
tliaii the line lens adjustments; (b) it is more easily sterilized by mo- 
mentary innnersion in pure jjlienol followed by washing in water; (c) 
its use does not require careful preliminary irrigation of the bladder. 
AVitli a freely 1)leeding ])ladder mucosa it is frequently impossible to 
obtain a clear view through a lens cystoscope in spite of continuous 
irrigation. With the direct instrument, on the other hand, we are look- 
ing through a clear stream of water Avliich is continuously entering 
the bladder and washing the observed area, and bleeding is seldom so 
great as to render examination impossible. Most beginners in the use 
of the lens cystoscope comjjlain of the difficulty in interpreting the 
held observed. Although the inversion of the object is now corrected 
by the latest lenses and the interpretation is somewhat simplified, 
nevertheless the magnification in the frequently blurred field is confus- 
ing to the novice. On the other hand, the direct natural view is readily 
and accurately interpreted in a comj^aratively short time. 

'"The direct cystoscope may also be employed as a iiretliroscope. 
While the view thus obtained may lack the magnified detail afforded 
by the lens instruments, the actual value of which is questionable, 
everything of i:)ractical imi:)ortance is clearly visible. Although the 
impo]"tance of routine urethral examination has undoubtedly been re- 
cently exaggerated, an instrument which will permit urethroscopic as 
well as cystoscopic examination is frequently of considerable value. 
Of particular interest is the direct inspection of the prostate from the 
viewi)oint of the pi'ostatic urethra from which the relative size, posi- 
tion, and IVe(|uently character of the enlargement is I'eadily ascer- 
tained." 

REFERENCES 

iKclly: Bull. Johns Hopkins IIosp., Dec, 1893. 

-Lewis: Jour. Culan. and Genito-Urinary Dis., ]!i()(i, p. 4-0. 

sElsncr: Pilchcr's Practical Cystoscop}', pp. 82, 83. 

•iLuys: Assn. frantj. d'Urol. Proc.-vcrb, 1905, Par., 190(i, pp. 407-482. 



248 CYSTOSCOPY AjStd urethroscopy 

DIRECT VIEW CYSTOSCOPY DURING PREGNANCY 

Cystoscopic conditions in general are particularly unfavorable in 
the pregnant woman, whose bladder is deformed and often displaced. 
Indeed, owing to traction exerted b^^ the inferior segment and com- 
pression exercised by the fetal head, the vesical cavity is considerably 
contracted in certain parts, especially at the fundus. This arrange- 
ment does not permit the movement of the cystoscopic jorism to a dis- 
tance sufficient to give a clear view of the fundus. IMoreover, it is dif- 
ficult to maneuver the elbow of the indirect cystoscope in the limited 
space thus reserved for the evolution of the instrument. 

On the other hand, these difficulties are not met with in direct vi- 
sion cystoscopy; because of its straight shape, it is easy of evolution 
and permits direct examination of the different parts of the bladder, as 



Fig. 160. — Diagrammatic section showing the aspect of the bladder in pregnancy. 

well as a clear view of the smallest lesions, with their exact size and 
situation. 

Bar and I undertook a series of investigations with my direct vi- 
sion cystoscope regarding the condition of the bladder in pregnancy,^ 
and among the facts brought out, these two are especially to be kept 
in mind: 1. The deformities of the bladder at the height of pregnancy. 
2. The displacement of the vesical orifices of the ureters in certain 
females. 

1. Deformity of the Bladder at the Height of Pregnancy. — For a 
long time obstetricians have called attention to the deformities and dis- 
placements of the bladder at the height of pregnancy. These deform- 
ities are the result of overdistention of the lower segment of the uterus, 
and particularly of the engaging of the fetal head. The bladder be- 
ing forced backward, permits itself to become distended Avherever pos- 
sible, and thus becomes deformed. 



i)n;i:r'i' cystoscopy Dunixt; piiecxaxcy 



240 



'riic (l('\iali()iis of llic hladdcf arc oflcii more apparciil lliaii rral. 
Tlic iiiKMiiial dislciiiioii oF llic various regions of llic or^^aii may ^-ive 
llic impression of a dcxialioii wliicli docs not fcally exist, at least, as 
jiid.iA'cd hy the Ncsicai tfinoiic, w liidi always remains in tlie median line. 
AVe ean readil\- iiiidersland thai lliis must l)e so, if we consider tlie faet 
that at llic lici.^lii oi' prc.^iiaiicy llic ulcro\-esieal ccHiilar lissuc is ex- 
tremcl.N' lax. This laxity <;ives to llic l)lad(ler a remarkable freedom 
of motion, as eom])ai-e<l ^vit^l tlie iilcnis. We must also take into con- 
sideration the fact llial llie uietlira (jn the one liaud, and the two ure- 




Fig. 161. — Frozen section of a pregnant female (after Zweifel).= The lateral portion of the bladder can 
be seen, much larger than the median portion. 



ters on the other, constitute real ligaments for the trigone, which con- 
tribute toward uiaintaining- it in its normal position. 

Nevei-theless, real deviations of the bladder may exist. The ves- 
ical ti-igone may not be median, in Ihe sense Ihat the two ureteral 
orifices are not equidistanl from llic sagillal V)lane. These deviations 
are due to the fact thai llie cellular 1 issue between Ihc l)ladder and 
the inferior segment, howcxcr Hahh) llie lalter may be, occasionally 
constitutes hul a feeble union bclwccn llic Iwo organ<, especially when 



250 



CYSTOSCOPY AXD UEETHEOSCOPY 



the lower segment is overdistended as is tlie case at the height of 
pregnancy. Tlie trigone can l3e actually deviated -when the nterns and 
its lower segment execute a rotary movement toward the end of preg- 
nancy, so as to bring the left edge of the organ forward. This rotary 
movement is generallj^ encountered when the lower segment distends 
itself more on one side than on the other; this condition is often ob- 
served in cervical presentation and also frequently in presentation by 
the breech. 

It goes without saying, of course, that when these deviations oc- 
cur, they will reach their maximum at labor. But they may also be ob- 
served during the last periods of pregnancy before the onset of true 
labor, Avhen the painless contractions of the uterus announce the im- 




Fig. 162. — Aspect of the bladder in a frozen section of a pregnant female (Barbour). ' Here too the lat- 
eral enlargement of the bladder can be seen. 



pending delivery and alread}^ modify the form and the position of the 
uterus. 

Of the various deformities of the bladder which the cystoscope has 
enabled us to observe in the living subject, Ave shall now consider only 
the most common and the most important of all; namely, that Avliich 
is observed during the final period of pregnancy wlien the fetal head 
is fully engaged. We are at once struck with one thing. In the me- 
dian line, the anterior and posterior Avails of the bladder are closely 
applied one against the other. The organ seems to be pushed down- 
Avard and flattened by the inferior segment. Above this median zone 
Avhich often leaves little space for the urine, an uiiper diverticulum 



iiii;i;ci' ('^ s■|■()S(•()^^ i)i-i:ix(i jm;k(;\axcy 251 

oL' coii,^i<l('r;il)l(3 size is seen; this loriiis llic vast jiockct wliicli is out- 
lined al)()\(' llio j)u])is ill so many ])r('^iiaiil woiiicii. 

Tills ])()ck-('l cxlciids I;i1cr;ill>- lo such a degree tJiat tlie bladder 
l)eiiig emptied, two •diverticula can be seen at tlie sides, unequal and 
quite dee]). These diverticula are best o])served in tlie Trendelenburg 
position. I'^i-equently they are found filled Avitli urine. In order to 
understand lliis desei'iplion better, the reader will refer to Fig. 100, 
where the i)icture of the bladder is quite characteristic. Let a trans- 
verse section be assumed passing immediateh'^ in front of the neck of 
the bladder and of the point of entrance of the ureters in the bladder. 
Imagine a sac having two walls, covering the inferior segment; on the 
median line the two walls touch each other; above, are the orifices of 
the ureters, U,U; below, the orifice of the urethra, D, and on the lat- 
eral walls, two diverticula, A,A, which are the last to empty tluMu- 
selves. In these diverticula a catheter or a cystoscope (since we are 
discussing cystoscopy) must be introduced to obtain the required dry 
medium, at least in the Trendelenlnirg position.. 

We have been able to demonstrate that this arrangement is the 
usual one when the fetal head is fully engaged, and we have every rea- 
son to believe that we have not been deceived by appearances. Con- 
sulting the color plates at our disposal, Avhicli rejoresent frozen sec- 
tions, we have found an arrangement of the bladder quite analogous 
to that which we are describing; and in a plate iDublished by Zweifel 
(Fig. 161), representing a transverse section (passing through the 
promontory and the upper part of the pubis) of a woman who died in 
labor, the same arrangement is shown. Barbour has also represented 
the bladder with a similar arrangement in a frozen subject (Fig. 162). 

EEFERENCES 

iPaul Bar and Geoi<;os Luys: Exameii dc la vcssic chez la fcmme enceinte, par le cystoscope 
a. vision direc'te (Societe d'Obstetrique dc Paris, Session of March, 1006). 

sZweifel: Zwei neuc Gefrierschnitte Gebarende, Leipzig, ISO.T; Plates 1 and 6, representing 
a transverse section. Tlie Madder is flattened medially: on the left side, the only 
side represented, the organ is prolonged distinctly outward and is much less flattened 
than in the median line. 

:!P,arl)our: Atlas of the Anatomy of Lalniur, Plate XXIT, Edinlmrgh, Johnston, ISPT. 

2. Relation of the Neck of the Bladder to the Ureteral Orifices. — It 
is interesting to detei'mine the relative position of the bladder neck and 
the ureteral orifices. Tn the Trendelenburg jiosition the vesical trigone 
is hoii/ontal; and when the cystoscope is inserted straight ahead into 
the hiadder and u]) to the fundus, then v>itlidra\vii slightly toward the 
bladder neck', wc can see the ])i-()je('ti(»n made by the transverse muscle 



252 



CYSTOSCOPY AXD URETHROSCOPY 



fibers (internreteral ligament) wliicli unite both ureteral orifices. The 
latter situated deeply and laterally, are on the same plane as t^ie neck 
of the bladder. But a quite different arrangement is noted at full term, 
especially in the primipara, Aylien the head of the fetus has fully 
engaged. 

In the noniDregnant woman, in the erect position, with the bladder 
empty, the anteverted uterus imi^resses a slight transverse fold on the 
vesical trigone, which is effaced in the Trendelenburg position, because 
of the traction exercised by the uterus on the upper jDart of the trigone. 

In the pregnant woman, especially in the primipara, this fold of 




Fig. 163. — Mew of the bladder and ureteral oritices in the pregnant female. L^.L', opening of the 
ureters into the bladder; D. urethral canal opening into the bladder; B, transverse plicature of the 
trigone; A,A, lateral prolongations of the bladder; C, direction of the cystoscope as it enters the bladder; 
C, direction of the instrument pointed toward the ureter. 



the trigone is often much more marked than in the nonpregnant, and 
it can be readily understood why it must be so. Because the expan- 
sion of the inferior segment is accomplished almost entirely at the ex- 
pense of the anterior wall, the neck of the bladder is pushed backward 
where it is held firmly by the uterosacral ligament and their intra- 
uterine extension. To a certain extent, when tlie bladder is empty or 
nearly so, the vesical trigone responds to the pull which the lower seg- 
ment exerts on it tlirough the action of the vesicouterine cellular tis- 
sue. The trigone, thus retracted backward, but held tightly upward 



DiKKCT ('^>■'r()S(•ol'^ dikixi; pui^cxancy 253 

;iii(l I'orwni'd 1)_\' the iii'clcrs ;ni<l (low iiw .".id niid lorward !i>' 111" ni'dlira, 
hccoiiK's loldcd on ilscll'. Willi llic woman In llic 'ri-ciidclcniaii-;;- posi- 
tion, lliis plica! ni'c is niain1ainc(l hccausc ol llic sli,i;!il dispiaeeinent of 
llie iilcnis. Tliis anaiii^cnicnt avc n'i)cal, is cs])ccially inai'lvod in tlie 
priiiiipara, \\licii llic ])i'csenlinft- part is lirinlx- cn^^a^cd and wlion tlio 
bladder neck' is sli-on,i;,l\- Infiied ])aek\vai'd; llic a])o\'c ai-ran,i;('iiicnt may 
be lackiii*;' in nuiltipar;T\ 

The appearance of tlie Jjladder wlicii the fetal liead is iiniily en- 
gaged, is well shown in P'ig. 168. In this position the ureters do not 
enter the bladder on the same level as the urethra, l)ut more or less 
higher np. 

3. Pathologic Vesical Deformities and their Relation to Ureteral 
Catheterization. — The deformities wliich we have just discussed are 
not without interest from the pathologic point of view, and they should 
not be forgotten when the ureters have to be catheterized with the pa- 
tient at full term. 

It is well to rememl)er above all, that the lateral diverticula in the 
bladder emi)ty themselves poorly; these partial retentions are there- 
fore of interest in connection with the tenacity of vesical infections 
during pregnancy. In one instance, I Imxe been able to note that the 
lesions of the vesical wall and the purulent deposits simulating false 
membranes, were found particularly in the right side of the bladder, 
external to the vesical entrance of the right ureter, where the bladder 
presented a sort of lateral diverticulum which emptied itself badly. 

We may presume that the pressure exerted by the inferior segment 
ujoon the uj^per part of the trigone, and the terminal portion of the 
ureters, favors the retention of the urine; that is perha]:>s not insignifi- 
cant from the point of view of the frequency with which the intra- 
ureteral retention of mine during j^regnancy, is observed. 

On the other hand, fi'om the standpoint of ureteral catheterization, 
the discovery of the ureteral orifices will be particularly facilitated, 
if we bear in mind tlie fact that these orifices should be sought, when 
the head is engaged, not below and outward, as in the nonpregnant 
subject, but further forward, above the transverse depression which 
projects above the bladder neck. 

In l)rief, the following rule may be laid down: In pregnancy, wlien 
the ureteral orifices are not I'ound innnediately, by the method of Luys 
which has just been dcscril^ed, they jiuist be looked for higher uj:) and 
furlhci- forward; llic\- will llien 1)0 easily found. 



CHAPTER VII 

CATHETERIZATION OF THE URETERS 

Ureteral catheterization constitutes one of the most impoi'tant and 
interesting applications of cystoscopy. The introduction of a catheter 
into the ureter, not only makes possible the complete exploration of this 
canal throughout its length and also of its corresponding renal pelvis, 
but it has numerous other applications besides ; to these we shall return 
later on. The most important are the following: 

1. The study of stricture or obliteration of the ureter and of the 
therapeutic measures applicable to these lesions. 

2. The search for calculi in the ureter. 

3. The treatment of renal colic. 

4. The exploration of the kidney pelvis either for a calculus, or as 
a general diagnostic measure, or to determine the capacity of the pelvis. 

5. As a therapeutic measure, to irrigate the renal pelvis in certain 
forms of mild pyelitis. 

6. As a therapeutic measure to assure the proper caliber of the 
ureter after ureterolithotomy. 

7. As a prophylactic measure to safeguard the ureters during gjn- 
ecologic operations, such as for cancer, fibroma of the uterus, etc.- 

8. For drainage and rapid closure of certain fistulse after ne- 
phrotomy. 

9. For the treatment of certain hydronephroses. 

How large a field is offered by ureteral catheterization is clearly 
evident, and we shall begin by studying the most practical methods of 
catheterization. We have two methods at our disposal, — with the in- 
direct (prismatic) cystoscope and with the direct vision cystoscope. 

URETERAL CATHETERIZATION WITH INDIRECT 
VISION CYSTOSCOPY 

Of all the indirect vision cystoscopes Avhich have been especially 
devised for ureteral catheterization, we distinguish two principal types; 
these have been studied carefully in the interesting monograph of 
Tmbert : 

1. Instruments in Which the Catheter Is Not Deflected. — 

Brenner's Cystoscope. — Brenner seems to have been the first to 

254 



CATTTETETJZATrOX OF THE ItllETEl^S 

iiiiiodiKM" a llcxiltle catlieter into tlie female ureter, in 1887. His m- 
striiincnt was a niodifieation of Nitze's cystosfO])o No. 2, and adapted 
to liis s])ec'ial ])iii|)os('.- It consisted of a piisiiuitie (indireet) eysto- 
scope willi the N'isual field and lamp siluatcil on tlic convexity oi' llie 
beak. Inferioi'ly and runnin.u- llii-ou,i;li the entire lenf;tli of tlie cysto- 
scope was a little channel for the ureteral cathetei'. '^i'lie inventor suc- 
ceeded quite easily in eatlieterizing the female ureter, but in tlic male 
all his efforts failed completely. 

BoissEAU DU Eociier's Megaloscope for ureteral catheterization 
presented tlie same arrangement and consequently offered the same 
disadvantag-es. The great difficulty in catheterizing the ureter with 
these instruments lay in the fact that the catlieter could not be de- 
flected and that it had to x^ass in a straight line from the urethra to 
the ureter. It was therefore necessary to tilt the handle of the cysto- 
scope very obliquely, and this was done only with great difficulty. 

2. Instruments in Which the Catheter Can Be Deflected. — AVith 
the ol)ject of remedying the principal faults just mentioned, tlie fol- 
lowing instruments were devised and constructed: 

TiLDEiSr Brown's Cystoscope. — Brown utilized Brenner's instru- 
ment. He modified it by constructing a fine stylet that could be in- 
serted into the interior of the ureteral catheter. This stylet had an 
elbowed vesical extremity, so that it could Ije extended about three 
centimeters beyond the tip of the cystoscope. The cystoscope is intro- 
duced into the bladder, the catheter canal being closed with an ob- 
turator. The latter is then -removed and replaced by the catheter and 
its stylet. The ureteral orifice is then sought, and when found, the tip 
of the stylet is directed upon it. By means of the stylet the extremity 
of the catheter can l^e given any position, and it thus becomes an easy 
matter to direct it toAvard the ureter. The author succeeded in cathe- 
terizing the male ureter with this instrument."^ 

Nitze's Cystoscope (First Model of 1896). — In his first experi- 
ments with uretei-al catheterization, Xitze surrounded his simple cysto- 
scope with an oval metallic sheath in which the uretei'al catheter was 
to pass. This sheath extended beyond both ends of the cystoscope, so 
as to permit the easy introduction of the catheter on the one hand, and 
also to give it the necessary flexibility, on the other. The metallic 
sheath was movable forward and backward, and From side to side, so 
that the tip of the catheter could be deflected in all directions and thus 
brought to the orifice of the ureter. 

This ])rimitive instrument bad the gi-eat disadvantage of being 
too bulkv, and its iiit rodudioii was, therefore, difficult. It was con- 



256 



CYSTOSCOPY AjSTD URETHROSCOPY 



sequenth' soon abandoned by its inventor, who adox)ted later improve- 
ments and developed another model, wliich is still very widely used at 
the present day (Fig. 164). 

Casper's Cystoscope. — This instrnment (Fig. 165) ai3art from the 
cystoseope proper, comj)rises a catlieter canal situated superiorly. Tliis 




Fig. 164. — ISiitze's cystoscope for wreteral catheterization; improved model. 

canal is covered by a deflector which serves to control the bending of 
the catheter; so that the further the deflector is introduced, tlie more 
will the catheter be bent, and the more it is withdrawn, the less will 
the catheter be deflected from the straight Ime. 

This instrument, which can be introduced more easilv than Nitze's 




Fig. 165. — Casper's ureteral cystoscope. A, electric lamp; B, prism; C, inferior orifice of a channel 
(gutter) which runs along the entire length of the instrument, and which is transformed into a closed 
canal by the sliding rod D, represented separately as M. The ureteral catheter traverses this canal; E, 
ocular. 

early model, does not, however, permit the easy introduction of a ure- 
teral catheter. Casper, therefore, devised a more recent model (Fig. 
166) in which the groove for the ureteral catheter is divided into two 
parts wdiicli makes possible the catheterization of both ureters with- 




Fig. 166. — Casper's doable ureteral cystoscope. 



out withdrawing the cystoscope from the bladder. This constitutes a 
very important improvement. 

Albaerax's Cystoscope. — Practical catheterization of the ureter 
Avas made possible by Albarran, who described it in 1897 (Fig. 167). 
His cystoscope* is comijosecl of several distinct parts: 1. The oxDtica] 



CATIIKTIOItl/ATlON Ol' T 1 1 K I ' IM/I'KIIS 



257 



jioi'lioii, I lie .^:('iii'r;il ;iit;iii,l;ciiicii1 of w liicli i- llinl of ;iii oi tli iin rv cvslo- 
scojx'. The I\\(» iirclcrnl or I ri-i^;i1 iiii;- poilioiis iii;i>- Ix' niomilcil upon 
lliis pnrl. ;i.- (IcsiicJ. l'. The iiiclcr.-il iiorlion consists of an open 
i;i-()()\(', wliicli is pi-()pcil>- .'Kljiislcd lo llic o|)1i(';il poi-Jioii. Aloni:- tlic 
sides of this ,i;i'()o\(' ai'c two lliiii stems ol" steel w liicli arc ('Oime('t('<l 




I'iR. 1()7. — AlLatran's simple cystoscope. 

with a (lelleclof at llie o|)ti('al pai1 of the e_\'st()se()])e. Tliis (h'flectoi' 
articulates \vitli a ,i;i-o()vc, and can assume any ])osition, l)et\\'cen the 
liorizontal and an aii,i;ie of loO de.^i-ces. AVlien tlie ■deflector is in tlie 
last ])Ositi()]i, i( is ])ei-IVctly adjusted to tlie terininal iiart of tlie GTOOve; 
this is tlie ])osition ol' the instrunient wlien not in use. Tlie move- 




Fig. 168. — AII)arran's cystoscope provided with its ureteral attachment. 

menis of the deflector ai'e controlled l)v a wheel, wliicli is i)laced near 
llie oculai- extremity of tlie instrument and raises or lowers tlie de- 
flector. The vault of the oroove is traversed by a canal for the ure- 
teral catlu^cr; the catheter emero-es in front of the deflector and lies 
dii'ectly upon it when it is inserted. By maneuveriii.ii- the wheel, this 




Fig. 169. — Albarran's deflector, whicli moves tl;e catheter and thns permits ureteral catheterization. 

arranu-eiiieiit peniiils the tip of the catheler to tak(,' any jtosition he- 
Iween the horizontal and an aii.ule of 140 (l(\jvi"<.'<'!^- Thus th(^ ani;'le of 
the catheter ina>' he chaii,i;'ed a1 will. The iir"1ernl ('li;iiiiiel ])resents 
exiernally a lillle hox which hears a small round riihher shield or cap, 
l)ierced I'oi- the passa,i;(' of Ihe catheler. \\y tijA'litenin.i;- the screw to 



PLATE XVI 

Fig. 1. — Typical aspect of a tuberculous ureteral orifice, indicating an ac- 
companjdng tuberculous pyonephrosis. A few ulcerations resembling 
nail scratches are seen outside of the ureteral orifice. 

Fig. 2. — Ttiiarculous ulcerations of the bladder seen with the direct vision 
cystoscope. 

Fig. 3. — Tuberculous ulcerations of the bladder treated with applications 
of the silver stick, through the direct vision cystoscope. The ulcerations 
represented in this figure, are the same as those in Fig. 2, but the 
central ulcerations have been touched with the stick. The impressions 
of the silver pencil are easily recognized. 




Fig. 1. 




FiK. 2. 



PLATE XVI 



Fig. 3. 



catiii:tI':i;i/ati()X ok tiik iiiF/ruRS 



259 



a greater or Jess degi'ee, llu; I'lilthci- shield is llaUcjiKMl and the vesical 
fluid is prevented From escaping, w liile the catlieter is enabled to move 
freely to and Ito. 

Al)ove tlie ureteral cliaiiiiel, tliere is another canal, provided with 
a little sto23cock; this channel is nsed for cleansing tlie lenses or irri- 
gating the bladder. This cystoscope and its attachment has a caliber 
of No. 25 Charriere. 

3. The irrigating portion is also closely fitted by a groove to the 
optical ai3i:)aratns. Tn tlie anterior convexity of this groove is found Jin 
irrigating canal v.hich opens near the lens and has a stopcock at its 
outer extremity. All of this constitutes an irrigating cystoscope which 
permits irrigation of the bladder and cleansing of the lenses. The de- 




pojiyi'/^ ""■ 



C. 



Fig. 170. — Bierhoff's modification of Albarran's cystoscope, permitting the simultaneous catheterization of 

both ureters. 



Hector renders catheterization simple and practical, and has been 
adopted nniversally by c^^stoscope makers. 

Israel's Cystoscope. — This instrument differs from Nitze's by 
having a doulile ureteral canalization, thus permitting the simultane- 
ous catheterization of both nreters, and also by having a movable irri- 
gating attachment. 

Bierhoff's Cystoscope. — This is an Al])arran cystoscope, modified 
so as to effect the simultaneous catheterization of both ureters (Fig. 
170). In this instrument, the optical portion to which the lamp is fixed 
is movable; it also avoids the disadvantage of tlic two meters cross- 
ing each otliei' when the cystoscope is willidrawn ami the eatlicters 
left in s'lfu in tlicii- i-cspective ureters. 



260 



CYSTOSCOPY AXD URETHROSCOPY 



WossiDi.o's Cystoscope. — This is also a double catheterizing iii- 
strnment. In this cystoscope the lens and the lamp are situated on its 
convexity, so that it is a simple matter to withdraw the instrument and 
leave the ureteral catheters in situ, without turning the cystoscope. 
Its caliber is 23 Charriere, and the ureteral channels will accept No. 5 
or 6 catheters, or even a single catheter of No. 7 caliber. 

Frank's Cystoscope. — Frank, of Berlin, constructed a cystoscope 




Fig. 171. — Freudenberg's cystoscope for catheterization of both ureters. 



with a correct image for the catheterization of both ureters by the ac- 
tion of a double wheel which controls the deflector of each catheter 
separately. 

Freudeistberg 's Cystoscope. — This author devised a combined cyst- 
oscope for catheterization of the ureters and bladder irrigation.'' This 




Fig. 172. — External tube of Freudenberg's cystoscope. 

was first presented before the Urological Congress of Paris in 1904; 
various subsequent improvements were sliown l)efore the Congress of 
the International Surgical Society, held at Brussels, in September, 
1905. 

This cystoscope presents two new j)rinciples : In the first place, tlie 



l^S 




Fig. 173. — Optical portion (telescope) of Freudenberg's cystoscope. 

lens, the lamp and the deflector are all on the convexity of the instru- 
ment; secondly, instead of a special channel for the ureteral catheter, 
there is a free space above the mounting of the optical portion in 
which the catheters move to and fro freely. 

One or both ureteral catheters may be directed by a guide placed 
in this free space; this guide has a deflector at its vesical extremity 



CATll KTKIM/AI'ION OF 'J" 



IKIiTERS 



2G1 



siiiiilai' 1() llinl of Alharraii. J^'iiially, llic optical jjorli(jii i.- not cir- 
cular, l)iil llatlciicd on one side, so tliat the visual field is made larger. 
Moreover, llic cnlirc optical ai)j)ai'alus iticliidiii:.': llio ui'ctci'al guides 
can Ix' I'ciiiovcd s('|)aratcl_\' •Aillioul llic iicccssit\- of witlidrawing tlie 
entire inslrunient. 

The advantages oT this iiisliuiiiciit are especially uotcwortliy in 



^=S 




Fig. 174. — Irrigating tulie of Frcudenberg's cystoscope. 



ureteral catlieterization. Indeed after the ureteral catheters have been 
iutroduced, if it is desired to leave them in the ureters without the 
cystoscope, it is unnecessary to turn the instrument on its axis in order 




Fig. 175. — Ureteral catheter guides for Freudenberg's cystoscope. 



to withdraw it. Tlie optical portion having been removed, it is a sim- 
IDle matter to withdraAv the cystoscopic tube by sliding it above the 
catheters without dragging them along. Another advantage is the 
possibility of using larger ureteral catheters than are possible ^vitll 




Fig. 176. — Cross section of Frcudenberg's cystoscope. A, optical portion of an ordinary cysto- 
scope; B,B. used more than portion A for the optical portion of Frcudenberg's cystoscope; 1 and 2, 
ureteral catheters. 



oilier instruments. I^'iiially, the ])ladder can he irrigated with this 
cystoscope witliout removing the entire apparatus. 

Baer's Cystoscope. — The principle of this instrument" is based on 
the fact that the laniji is o])en on two sides. The optical apparatus is 



262 CYSTOSCOPY AXD UEETHROSCOPY 

easily intercliangeable, and permits the examination of tlie entire ves- 
ical cavity, of simple or double ureteral catheterization, and e^en of a 
few intravesical maneuvers. The many adaptations of this cystoscope 
explain the name ''universal cystoscope" which is generally given to 
it. But it is hard to keep it in order. It is preferable by far to have 
several cystoscopes each of which should be used for its own special 
purpose. 

Apart from the cystoscojDes just mentioned, the manufacturers 
have in recent years devised a series of improved models in Avhich the 
visual field has been enlarged and the eiuployment of relatively large 
ureteral catheters made possible. However, No. 8 is generally a max- 
imum size, beyond which it is difficult to pass. Likewise, double cathe- 
terization of the ureters has undergone considerable improvement 
with prismatic cystoscopes, with the result that this important pro- 
cedure is being carried out with comparative facility. [American 
cystoscope makers have made Avonderful progress in the past few 3^ears 
in this industry and are noA\' providing unrivalled instruments for ex- 
amination, catheterization, and intravesical operative purposes. Only 
within the last few months, one manufacturer has jDut on tlie market 
a universal instrument, having a comj)aratively small caliber, which, 
nevertheless, has a large visual field, a strong illumination, and a single 
shaft which can be utilized for all cystoscopic purposes, thus making 
it possible to perform all endo vesical work with this single instru- 
ment. — Editor.] 

REFEREN^CES 

ilmbert: Le catheterisme des ureteies par les voies naturelles, Montpellier, 1898. 

2Breuner: Leiter catalogue, Vienna, 1887. 

sBrown, F. Tilden: Johns Hopkins Hospital Reports, September, 1893. 

4Albarran: Maladies chirurgieales du rein et de I'uretere, in Traite de Chirurgie, by Le 

Dentu and Delbet, Paris, 1899, Tiii, 608. 
sFreudenberg : Ann. geuito-urin., March 15, 1906, pp. 401-411. 
6Baer: Un uouveau cystoscope, Tr. Assn. franc. d'Uroi., 1904, p. 802. 

URETERAL CATHETERS 

There are three types of ureteral catheter which are most com- 
monly used; i.e., with an olivary tip, Avith a round end, and Avith a 
flutelike beak. These models are A^ery much to be preferred esiDccially 
Avlien dealing Avith a normal ureteral orifice. Catheters Avith an oliA^ary 
tip are x^articulaiiA^ couA^enient for ureteral orifices Avliich are narroAV, 
strictui'ed or otherAvise diseased, for they can be inserted more easily 
than the other types. The flute-tii:) catheters are esi)ecially desirable 
for therapeutic purposes. The catheter is generally about 70 centi- 



CATii i:r!;i;i/.\'ri(».\ oi- 'I'iik ii;i:'ii:k.s JIjo 

meters ill Irnnlli, aiiil i> iisii;ill>' .uradiiatc*! in (•ciiliiiiclei's. Tlic calilx'i' 
vai'ics Troiii Xo. 5 to Xo. 8; tlir sizes inosl coiiiiiioiily iisecl are Xos. (i 
and 7. 

TECHNIC OF URETERAL CATHETERIZATION 
WITH THE INDIRECT CYSTOSCOPE 

To ])ra('li('e callielerizatioii willi llie cystoscope, certain systematic 
ste])s are essential. These ai'e (lesci'ilxMl l)y Alhari'an, as follows: 

1. Preparation of the Instrument. — All the parts are sterilized, — 
cystoscope, eatlieteis, foreeijs, electric condiictino; ^\•i^os, — in a formalin 
sterilizer. The hands of the operator are sterilized as if for an opei'a- 
tion. The instrument is thoronglily tested in all its parts. It sliould 




Fig. 177. — Position of the cystoscope and the hands in catheterizing the left ureter (Gorodichze and 

Ilogge) .1 

be well cleaned and the lamp in perfect ordei". The catheter is in- 
serted into the ureteral canal, care being- taken to have it ^vell lubri- 
cated with .lilycerin so that it will slide in easily. 

2. Preparation of the Patient. — In tlie male, the ojx'iator sliould 
be assured that the calilx'r of the urethra ^^"ill admit a Xo. 25 French 
sound easily. In both sexes the bladder is washed out thoroughly so 
as to secure as clear a visual field as jjossible; it is then iilled with 150 
to 200 c.c, of boric solution, the minimuni amount of lluitl for cystos- 
co])y being from 50 to GO c.c. 

l\. Introduction of the Instrument. — The tip of the instrument is 
lubricated with steiile u'lvcerin and introduced into the urethra like an 



264 



CYSTOSCOPY AND URETHROSCOPY 



ordinary sound, wliile an assistant protects the catheter from external 
contact. ^ 

4. Finding- the Ureteral Orifice. — The cystoscope is introduced far 
enough for its tip to be free in the bladder. The beak is then turned 
downward and outAvard, giving it an inclination of about 30 degrees to 
the horizontal. The lamp is then lighted and the ureteral orifice will 
quickly be seen. 

5. Getting the Ureteral Orifice Into the Visual Field. — When the 
ureteral orifice has been found, it is well to fix it so that the intro- 
duction of the catheter will be made more easily. In a general way the 
button attached to the ocular of the cystoscope may be used as a guide 




Fig. 178. — Position of the cystoscope and the hands in catheterizing the right ureter (Gorodichze and 

Hogge) . 



to bring the ureteral orifice and the beak of the instrument as closely 
together as possible. The latter will be very near the ureteral orifice, 
and the catheter, in emerging from the cystoscope, will have a rela- 
tively short passage to make to enter the ureter. 

6. Position of the Surgeon's Hands. — At this moment the position 
of the operator's hands is important. One hand holds the cystoscope 
in position and manipulates the wheel which controls the deflector; the 
other hand inserts the catheter.^ In catheterizing the right ureter, the 
right hand controls the cystoscope and deflector and the left inserts the 
catheter; for the left ureter, the left hand controls the deflector and 
the right inserts the catheter. In a general way, it is w^ell to use both 



CATiiK'i"i:i:i/A'ri()X oi- 'I'iik ri;i':Ti:i;s 



2(1.") 



hands sijimltaiM'ouslv- ; llial is, while one hand is iiisciiiii.t;- tlic catheter, 
the other hand, at (he same time controls llic inoNcnicnts oT the (h'- 
llcctoi- and thus ^■iii(h'S tlie cathetei-. 

7. The Ureteral Catheter is Inserted Gently. 'I'hc catheter a])- 
])('ars in the \isual licld, and as ahovc (h'sci-ihcd, the (h^nector is low- 
civd so that the tio of the catheter is seen near the pri.-in, considerahly 



inau'lillied 





Fig. 179. 



Fig. 180. 





Fig. 181. 



Fig. 182. 



Fig. 179. — Ureteral catheter in favoral)lc position for easy entrance into the ureteral onlicc. 

Fig. 180. Ureteral catheter in poor position, and can not enter the ureteral orifice without great 

difficulty. 

Fig 181. — The ureteral catheter has entered tlie rit;ht ureter. The button indicator on the cysto- 
scope is well placed vat eight o'clock). The ureteral orilice is ir. line with its prolongation (Gorodichze 
and Ilogge). 

Fig 182.— The ureteral catheter has entered the left ureter. The button indicator on the cysto- 
scope is well placed (al four o'clock). The ureteral orit^ce is in line with its prolongat on (Gorodichze 
and Iloggc). 

S. The Catheter Tip is Inclined in the Direction of the Ureteral 
Orifice.— Idiu tip oL* the catheter, -eiitly i)Ur^lied forward and bent by 



266 CYSTOSCOPY AXD URETHROSCOPY 

the deflector, as desired, recedes from the prism, becomes smaller and 
enters the ureteral orifice. 

9. The Catheter Penetrates the Ureteral Orifice. — This is^ perhaps 
the most delicate movement in ureteral catheterization. Using both 
hands, as above suggested, the cystoscope is raised or lowered at the 
same time so that the catheter will enter the ureteral orifice more eas- 
ily. The tip of the catheter should be given the same direction as the 
ureter (Fig. 179) to avoid its striking the bladder wall, which will hap- 
pen if the tip is too high or too low or in front of or behind the 
orifice (Fig. 180). 

The ureteral catheter having entered the lips of the meatus, it is 
an easy matter to advance it up to the pelvis. It is well, for a moment, 
to leave tlie deflector in the position which has facilitated the intro- 
duction of the catheter; it will then be found much more convenient to 
lower the deflector, as this enables the catheter to slide more easily into 
the ureter. Otherwise the catheter may rub against the ureteral wall 
and unforeseen accidents may occur. 

On the other hand, when the operator is assured that the ureteral 
catheter has penetrated its entire length without difficulty, he may be 
certain that its tip has reached the pelvis. In order to determine when 
"the advance of the catheter should be stopped, the best criterion is 
either to judge by the resistance felt by the hand, or as is most often 
the case, by the fact that its progress has ceased and that it bends upon 
itself at the ureteral orifice. This bending of the catheter at the orifice 
indicates that its extremity has reached the pelvis ; it is well to with- 
draw the catheter at this point one or two centimeters, so as to i)revent 
injury to the renal parenchyma. 

10. Withdrawing the Cystoscope and Leaving the Catheter In Situ. 
— The catheter being in position, the deflector is lowered so that it lies 
flat against the cystoscopic tube. This precaution is absolutely essen- 
tial, and one not to be forgotten, in order to avoid injury to the urethra 
and the severe pain that accompanies it. Next, the lamp is extin- 
guished, by turning off the current. This done, the cystoscope is de- 
pressed in line with the axis of the body, one hand feeds the ureteral 
catheter into the cystoscope, while the other withdraws the tube. 
AVlien the beak of the c3^stoscope has reached the meatus, the ureteral 
catheter is grasped with two fingers, while the operator withdraws the 
cystoscopic tube and thus leaves the catheter in place. 

REFEREliTCE 

iGorodichze and Hcgge: Catlieterisme ureteral at diagnostic des affections renales, Liege, 
Ch. Desser, 1913. 



CATIIIOTKIMZATION OV TIIK URETERS 207 

URETERAL CATHETERIZATION WITH THE 
DIRECT VISION CYSTOSCOPE 

( iriiiirdd, of \'i('iiiia,' seems to litivc IxM'ii tlic lirsl to jji'ad ice calli- 
('t<'i'i/a(i(»ii of tlic iii'ctci- willi a (lircct vision cystoscoix'. His insli-ii- 
iiieiit consisted of a metallic tube l)lackeiie<l inside, with a mii'ioi- ])la('e<l 
at its extremity. A frontal mirror with an electric lain]), ])rovide(l the 
luminous rays and revealed the ureteral orifices. 

For ui-eteral cathetei'ization, Ciriinfehl made use of a special cath- 
etei-, the caliher of which was No. 6 Charriere, and which he iuti'oduced 
into the bladder, not through the endoscopic tube, Init along its ex- 
terior wall. This catheter was traversed by a metallic wire whicli ter- 
minated at one of its extremities in a ring, by which the wire could be 
pulled. Two other fixed rings formed a fulcrum. The otlier extremity 
was jointed in such a manner that the catheter could be bent more or 
less and made to assume a variable acute angle with the rest of the 
catheter. 

The tube was introduced into the uretlira. Next the catheter was 
inserted into the bladder, in such a manner that the catheter was placed 
on the left side of the tube when the right ureter was to be catheter- 
ized, and vice versa. The operator then sought tiie ureteral orifice 
through the endoscope, and when it was fou^id, the catheter was genth' 
inserted into the meatus. The endoscope ^yas next easily withdrawn 
from the urethra, and the catheter left in situ. 

Pawlick, in 1896,- catheterized the ureter with a method different 
from that which he first used; this consisted of an endoscopic tube 
which we have already described (see page 58), with whicli he could 
see and catheterize the ureteral orifices with the aid of the special 
catheter shown in the accompanying illustration (Fig. 183). He even 
pu])lished numerous reports in which he was able to apply his pro- 
cedure, but only in the female." 

Kelly's Method. — Howard Kelly, of Baltimore, has rendered most 
im])ortant service to the subject of direct ureteral catheterization, 
through his many jjublications, their important character, and their 
study of the most minute details. A¥e shall not now describe his in- 
strument, as it has already been fully described on page 57, but shall 
merely discuss its bearing on the subject of ureteral catheterization. 

The ])atieiit being in the genupectoral ])()sition, the im|)()rtant thing- 
is to discovei- the ureteral orifices. Kelly gives his tube an obTKiue in- 
clination of about ?A) degrees, and by making it vary slightly, and by 
watching carefullx , the ureteral orifices can thus be seen. The ureteral 
cathetei- is then inti-oduced and advan.ced gently as far as the kidney. 

The greatest difficulty in this procedure is that of recognizing the 



26S 



CYSTOSCOPY AXD rEETHEOSCOPY 



ureteral orifice. This end Avill lie aided by tlie use of an explorer or 
searelier. a sort of fine stylet. pro\dded A\dtli a sniootli mn^ sli.^-fitly 




Fig. 183. — Pawlick's ureteral catheters. 



Fig. 184. — Kelh-'s ureteral explorer. 



curved end. and a little hent handle (Fig. ISrl). AAiiich does not inter- 
fere with the operating view. 



("ATIIKTKi:iZATl()X ol" TIIK niHTEKS 269 

Evacuation of llic iirliic is al-o a dirficiill mallei-. Kelly removes 
llic urine eitliei' willi a melnllic calheler |)i'o\i(|e(| villi a riililxM- hull), 
or willi coUoii lampoiis. These iiiani])ulalioiis do not (•()iii])i('t('l y iv- 
iiioNc the ui-ine, howcNcr, and iKM-cssitate a eonsidei-altic loss of time. 

Ilowexcr Ihis may he, we must see 1lie skill an-l dexterity Avitli 
wliicli Kell\- liimseir cal liele|-izes the reinaie ui-elei-. hefore \ve can 
un(h'rsland how cNcn willi his sk'ill this procedui'e can he of any vahn'. 

REFERENCES 

idiiiiifi'lil : I)i:' Kii(1()skn])ie der lliiviuiilirc uml ]'.l:isc, Dcntsclic ('hiiur^ic vnn I'.illiolli iiii<1 

Lueckc, 1881, No. 51, special, p. 211. 
-Pawlick: Zentralbl. f. Gyiiak., 1896. 
aPawlick: Rev. de oyiii'o. et de r-hiv. al.d., Rept.-Oot.. 1807. pp. 787-823. 

TECHNIC OF URETERAL CATHETERIZATION WITH 
LUYS' DIRECT VISION CYSTOSCOPE 

The operative teclmic of my cystoscope lias already l)eeri described 
(see page 229). It is therefore not necessary to repeat it at this time. 
The patient being in the inclined position, and the cystoscope in the air- 
distended bladdei', the first step is to iind the ureteral orifices. 

Finding the Ureteral Orifices. — AVhile it is qnite easy for the ex- 
perienced, the search for the ureteral orifice is nmch more difficnlt for 
the beginner. One ninst know the exact topography of the bladder, 
■which takes on a rather special significance nnder the action of the in- 
clined position of the pelvis. 

The most valnable gnide in finding the ureteral orifices immedi- 
ately, is this: The cystoscopic tube is inserted into the bladder up to 
the posterior wall. AVhen the tube is ^vlthdl•a^\•n horizontally, we see 
first only the posterior Avail, because the fioor of the l)ladder lies di- 
rectly under tlie tube; withdrawing the tube still further, the fioor, 
very deep at first, now comes into vi(^w suddenly. There is a very 
clear-cut line of deuuircation at this point, which is very easy to ob- 
serve; and it is precisely when tlii< uioment is reached that one can be 
certain of being dirt'ctly u])ou the inlei-ureteral ligament. Conse- 
quently, by slightly inclining the tube to the right or to the left, the 
corresponding ureter will be found. 

Let us hasten to add that the most common faull in this procedure 
usually consists in inclining the tul)e too much 1o one side. As a gen- 
eral rule, it may be said that the orifices are not far from the me(lian 
line, but the tendency is to get too far away from them. 

AVhile the discovery of the ureteral orifices is a simple enough 



PLATE XVII 

Fig. 1. — Urethral aspect of polypi on the neclc of the bladder. These 
polypi could not be recognized except through the direct vision cysto- 
scope, by the aid of which both urethral and vesical aspects of the blad- 
der neck can be examined. 




PLATE XVII 



CATIIKTKIMZATIOX OK TIIK riM'/PKn.S 



271 



mallei' iiiidci- normal and nsual condilions with llii- pi-of-c'durc i1 is 
allo.H'cl licr dilTcrcnl in acnic ('_\>lilis, oi' w lien llif vesical \\;dl i> uranu- 
lai", OI" iiillamcd, and hiccds a1 llic slii^lilcsl conlacl, oi' w licii fnaiiipula- 
iion is very ])ai!irul. 

(\'riaiii ral licr special itroccdiircs will llicn hccomc ncccs-.-irx-: 
F'irsl, ii \\ill Ix' necessary to conlrol llie pain. Idie l>o\\c!s liaN'inc" 










(^' oflr, ^^? 2 



Fig. 185. — Finding the ureteral orifices with I,uys' direct vision cystoscope, the bladder being di- 
lated under the influence of the inclined position. The endoscojiic tube is first introduced into the 
lundus of the bladder, in first position; then it is gradually withdrawn to second position; suddenly, the 
fundus reappears toward the tube; it is now at tlie inlerureteral ligament, which is a most valuable 
guide. All that is now necessary is to incline the tulie laterally somewhat and place it in third position, 
and the ureteral orifice will surely be found. 



l)oen einplied, tlie patioiit is .i^-iveii a ix^taiiied enema, lialf an liour l>efore 
the examination, consistini;' ol' one or Iwo urams of an1ii\\iin and 
twelve drojjs of laudanum. Sometimes this is iiisul'licieiit ; the Madder, 



272 



CYSTOSCOPY AND URETHROSCOPY 



being liiglily sensitive, rebels at tlie slightest contact, tbns making an 
examination extremely difficnlt if not altogether impossible. ^In tliese 
conditions it may become necessary to resort to hypodermic injections 
of morphine or of scopolamine, as has been recommended by Terrier. 




Fig. 186. — View of the left ureteral orifice magnified by the lens of Luys' direct vision cystoscope. 

I have had occasion to apply the la.st mentioned procedure with 
great success in the service of J. Ij. Faure, in a patient of Lapointe's. 
The bladder was particularly painful, but with this method of anesthe- 
sia, it was possible to catheterize the ureters. 



CATii i;'n;i;i/,A'i'iox oi' ■iiii-; iiiktkks 273 

fSccoiid, it will ol'tcii lie iicccssni'X' to conli-ol tlic Wlccdiii^- of llu,' ves- 
ical iiiucosa. Wiu'ii tlic cystitis is xvvy pi-oiioiinccd, tlic vesical wall 
bleeds at llic slig'litest contaet, and the hlood completely ol)seures the 
field of N'isioii; it is then im])0ssi!)le in sj)ite of llie re])eated use of eottoii 
tampons, to distiii<j,iiisli the details of the vesical imicosa cleai'ly. In 
these eii'cumstances it may ])e extremely difficult to lind the iii'eteral 
oi'ifices. 

A veiy simple pi'oeedure will overcome these difficnlti(\'<. Ifavinfi' 
stanched the l)lood Avitli a cotton tampon, it is usually sufficient to 




Fig. 187. — IJirect catheterization of the left ureter. When the ureteral orifice has been well located, a 

ureteral catheter enters the ureter easily. 

apply to the bleeding point, another tampon saturated with a 1:1000 
adrenaliii solution, in order to make certain after some moments, that 
all bleeding has ceased. Great care is necessary, however, for this stop 
to have a proper effect. It is absolutely essential th.at the adrenalin'he 
placed only on the actual bleeding point; this agent i^ effective only 
Avhen applied to the bleeding si:)ot. 

Third, the uretei'al orifice may not be located, although the extrem- 
ity of the cystoscoi)ic tube has been directed exactly upon the point 
which should normally correspond to the uretei'al orifice. Tn such a 



274 



CYSTOSCOPY AND URETHROSCOPY 



5^ 



\\*o 



Fig. ]8S. 



Fig. 189. 



Fig. 188.— Small catheter provided witli a metallic stylet for direct catheterization of the ureter in the 

female. 

Fig. 189. — Ureteral catheter devised especially for direct catheterization of the ureter. 



("ATM i';ri:i;i/.\'ri().\ (»i' ■nii; iiiKTioits 



275 



case, it is well lo slrdcli llic xcsical iiiiicosa hy (|('i)r('ssin,u' i1 willi 1!k' 
li|» of 1 lu' cysloscopic I iihc In I his iiiaiiiicr, a u id era I (Hilicc is |-c\('al<'<|. 
wliicli was liiddcii hchiiid a fold of I he iiuicosa, and was lliiis inacccssihlc 
at llic lirsl cxaiiiiiial ion. 

Aiiotlicr ])i'()('('diir(' is to wait for tlic ureteral ojaciilalion, wliicli 
acts as a i2,uid(' lowai'd llie source of the jet; in this way, the ureteral 
meal us can ol'len he locatcMl. 

l^'ourlli, lliei-c ai'e eases in wddeli, in S])i1e of all ])alienec ;ind cai'O, 







V 



A \ m/ ffSi 








Fig. 190. — Direct ureteral catheterization in the male. 



the ojoerator does not succeed in locating' the ureteral orifice. In these 
assuredly rare cases, the method reconnnended hy Voelcker and Joseph, 
for prismatic cystoscopy should be adopted. Ten minutes before the 
examination, a subcutaneous injection of 4 c. c. of a sterile 4 per cent 
solution of indio'ocariniiie is given. The urine is 11ms coloied dark blue 
at the end of iiftecMi minutes, and at the moment of ejaculation it is eas)^ 
to see tlie exact point at wliicli the colored urine cmei'ges; namely, the 
ureteral oritice. 



276 CYSTOSCOPY AXD TRETHROSCOPY 

Ureteral Catheterization (Luys). — When tlie ureteral orifice has 
been located, it is well to place the lower margin of the CYstosco^ic tu])e 
directly in contact witli it (Plate XIII, Fig. 2). The cystoscope is then 
fixed firmly with the left hand, while the sterile ureteral catheter is 
introduced with the right. The catheter is directed along the floor of 
the tube and quite naturally enters the ureteral orifice in the easiest 
possible manner, progressing as far as the pehis and kidney. This 
entire iDrocedure appears to be extremely simple and remarkably easy 
of performance. 

The sole jDrecaution to l)e taken is to liaYe a Yery straight and rigid 
ureteral catheter. When the catheter is new, this condition is usually 
present; but after it has been used some time, it becomes soft and it 
no longer has the necessary rigidity to adYance beyond the ureteral 
meatus. 

In these circumstances we place a fine stylet of wire mthin the 
lumen of the catheter. This stylet must not extend to the end of the 
catheter in order that the catheter tijD shall be yielding, and not danger- 
ous, still sufficiently rigid so that it Y\'ill not strike the ureteral orifice 
and bend on itself. Once the tip of the catheter lias engaged in the 
ureter, the stylet is withdrawn and the catheter is adYanced into the 
ureter as far as the pelYis, if so desired. The handle of the cystoscope 
is withdrawn, and with it comes the cystoscopic tube proper. 

For ureteral catheterization in the female, we use a short straight 
ordinary catheter. No. 5, 6, or 7, which is usually sufficient for collecting 
the separate urines, or for examination of the lower extremity of -the 
ureter. 

I haYe deYised a special ureteral catheter for the male, so as to 
obYiate the use of the stylet. The catheters most commonly used cor- 
resjDond to Xos. 7, 8, or 9, Charriere; their tips are cut Ijlunt and haYe 
two eyes laterally. Their tip is soft and flexible for a distance of one 
centimeter; then for about fifteen centimeters they are of a little harder 
substance, which is more resistant and capable of furnishing sufficient 
I'igidity. The rest of the catheter is flexible and ends in a broad funnel, 
to which the cannula of a syringe can be attached. These catheters 
penetrate Yery readily into the ureter and facilitate laYage of the pelYis.. 

In actual practice, howcYer, these catheter models are not indis- 
pensable, and in the Yast majority of cases, CYcn in the male, ordinary 
ureteral catheters can be used, proYided they haYe a fine stylet which 
is well lubricated and particularly smooth and clean. Oj^erating in 
this way, ureteral catheterization really becomes Yery easy, and with 
experience, can be performed Yery rapidly. 

The picture of the ureteral orifices seen with the direct Yiew cysto- 



CATHETERIZATION OF THE URETERS Z( ( 

scope is so clear and distinct, tliat general surgeons and obstetricians 
who do not specialize in urinary surgery, readily succeed even after the 
(irst allciiipl. 'IMius Tyiw, who liad never examined the bladder with a 
cystosc()])e, and had never catliclerized the ureters, was able to catheter- 
ize at the very first trial, Tn the same way, Lapointe, a surgeon in the 
hospitals of Paris, also wrote me on August 11, lOOG, that he liad 
catheterized both ureters in a normal bladder with my instrument with 
the greatest ease. 

Pierre Delbet reported to the Surgical Societ}^^ "The ureteral 
orifices are readily seen; and as the ureteral ejaculation takes place in 
an empty bladder, distended only by air, each drop of urine is seen with 
extraordinary clearness. In a case in which it was not at all necessary, 
I was tempted childishly to insert a catheter into the ureter simply for 
the pleasure of doing so, and it was done just as easily as insertng a 
probe into a cutaneous fistula." 

I therefore believe that it is infinitely preferable to catheterize 
with the direct cystoscope, than across a cystotomized bladder, as has 
been suggested by Legueu.^ One can always see better in the closed 
bladder with my cystoscope than in the open bladder, without, at the 
same time, assuming the risk of an operation. 

The following are reports of a few cases in which this method Avas 
especially useful: 

Case 1. — Left Pyonephrosis: Examination of the Separate Urines Showed an Absence 
of Left Kidney Function; Direct Catheterization of the Left Ureter Showed the Exact, Site 
of the Obliteration. 

A woman, aged forty years, entered the service of Beurnier, at Tenon Hospital, in No- 
vember, 1904. She presented a large tumor in the left hypochondrium ; it was movable 
transversely, but very little vertically, and was suggestive of a tloating kidney. The urine 
was clear, and bladder capacity excellent. The previous history showed attacks of nephritic 
colic for a long period, and always on the left side. Vaginal examination showed that the 
inferior extremity of the left ureter was distinctly painful. 

Endovesical separation of the urine on November 23, made by me, gave the following 
data: On the right side, clear urine, with distinct ureteral ejaculation; on the left side, 
not a drop of urine. • The conclusion was evident that the entire clear urine was being fur- 
nished by the right kidney, and that the left kidney had no functional value because its 
ureter was obliterated. 

In order to determine the exact site of the olistructioii. I catheterized the left ureter 
with my cystoscope, with the aid of Eabinovitch, intern of the service, on November 29. 
The right ureteral orifice was absolutely normal; the left orifice, on the contrary, was red, 
puffy, and surrounded by a very pionounced inflammatory zone. Nevertheless, this orifice 
was immediately catheterized with the greatest ease, as soon as it was located. The catheter 
penetrated easily into the ureter, but was obstructed at a point about 2-i centimeters from 
its orifice, and it was impossible to advance it any further. It bent and twisted under the 
eye in the cystoscopic tu1)e, and made no further progress. It was noted that no urine came 
through the orifice, not even when asj^iration was attempted at the free end of the catlieter. 
The action of the piston proved that there was an actual vacuum in the lumen of the catheter ; 
the latter, on later examination, was found perfectly patent. 

We were, therefore, dealing with an obliteration of the left ureter near the kidney. 



278 



CYSTOSCOPY AND URETHROSCOPY 




Oeiri. 



anastomosis, followed by seconaarj i '^ .u^ 5 iV,p interior of the oelvis with two orifices; one is the 



CATHETERIZATIOISr OF THE URETERS 279 

This diagnosis was confirmed at operation on the following day. Beurnier performed left 
lumbar nephrectomy and found a closed pyonephrosis; the ureter was completely obliterated 
by the perinephritis. The specimen is preserved in my private collection. 

Case 2. — Intermittent Hydronephrosis : Separation of the Urines during the Period of 
Betention; Vreteropyeloneoslomy ; Direct Ureteral Catheterization ; Nephrectomy. 

On Dec. 8, 1904, Tuffier asked me to effect separation of the urines in a woman twenty- 
five years of age, who had entered his service at Beaujon Hospital two days previously. She 
complained of extremely severe pain, resembling renal colic, and always on the left side. 
These painful attacks began nine years previously, at the age of sixteen. During these 
attacks, a large tumor formed in the left hypochoudrium, while at the same time, urinary 

Ordinary Diet 
right kidney left kidney 

From 10 to 10:45 A.M. 

V=155 c.c. V = 27 c.c. 

A = -1-21° A = -0.24° 

From 2 to 2:45 p.m. 

V = 150 c.c. V = 25 c.c. 
A = -0.78° A = -0.26° 

From 4 to 4:30 p.m. 

V=z 60 c.c. V=30 c.c. 

A = -1-12° A = -0.20° 

Partial Milk Diet 
12 to 12:45 Noon 

V = 1C0 c.c. Vz=30 c.c. 
A = -0.85° A = -0.21° 

1 to 1:45 P.M. 

V = 96 c.c. Y = 27 c.c. 
A = -0.86° A = -0.25° 

4 to 4:45 P.M. 

V = 105 c.c. V = 32 c.c. 
A = -0.86° A = -0.22° 



V = Volume. A = Freezing point (in Cryoscopy). 

secretion diminished in quantity. This phenomenon lasted several hours, at times, several 
days. The attack usually ended with a profuse emission of urine, cessation of the pain and 
disappearance of the abdominal tumor. The passage of a stone was never observed. The 
urine was continually clear, and there was never any trace of blood. 

When I first saw her, she was in the midst of one of these attacks. A large tumor was 
felt in the left hypochoudrium, movable, kidney-shaped, and strongly suggestive of a float- 
ing kidney. The urine collected with a catheter was absolutely clear. Tlie urine separator 
was introduced easily and left in place for fifteen minutes; the right side showed rhythmic 
and regular emissions, although somewhat slow, for the patient had taken nothing during 
the entire morning ; on the left side, on the other hand, not a single drop of urine was passed 
during that entire period. An assistant who attempted to push the tumor upward toward 



280 CYSTOSCOPY AND URETHROSCOPY 

the diaphragm, met with no success. When an attempt was made to grasp the tumor be- 
tween the two hands, the same negative result followed. 

The diagnosis was therefore very evident, — a closed uronephrosis. Tuffi^- operated 
immediately after this examination. The leic kidney was exposed, but as it was too large 
to be delivered into the wound, it was first punctured; more than half a liter of fluid escaped. 
The pelvis was then freed and was found enormously dilated, and the ureter which followed 
it was small and kinked near its origin. Tufifier did a pyeloureteral anastomosis, connecting 
the lower end of the pelvis with the ureter (Fig. 191). Tlie operation was finished in the 
usual manner. 

For eight days the patient progressed very nicely, but a lumbar fistula then formed, 
and almost all the urine was eliminated through the lumbar wound. The dressings were 
soaked with urine continually. To remedy this condition, I catheterized the left ureter on 
December 27, with great facility, and the ureteral catheter was left in sitit, for two days. 
On Januai-y 3, 1905, the patient was in good general condition. The lumbar wound was 
almost closed and no urine passed through it. 

During the forty-eight hours in which the catheter was left in the ureter, the separated 
urines were examined chemically by Maute, and showed that the functional value of the 
left kidney was almost nil. The table on page 279 shows the analyses. 

In view of these findings, which demonstrated a complete functional insufficiency of 
the left kidney, Tuffier decided to perform nephrectomy. This proved to be very difficult 
because of the strong adhesions that had been formed. The renal parenchyma was found 
extremely diminished; the pelvis was dilated to double the size of the kidney. A probe 
introduced into the lower part of the ureter penetrated directly into the pelvis across the 
newly formed opening; at the side of this new opening, the former ureteral orifice was 
seen, normal in size (Fig. 191). 

By means of a minute dissection of the entire ureteral canal, it was possible to follow 
the canal from its origin at the pelvis up to the ureteral anastomosis, and it was found 
twisted upon itself in the form of a loop. A probe could not be passed from the normal 
ureteral orifice to its lower extremity because it was stopped at the uretero-pyelo-auastomosis. 

From this case, therefore, we may draw these conclusions: 

1. Separation of the urines demonstrated that the kinked ureter did not allow the 
urine to pass through, for not a drop of urine had been collected from the left side. 

2. The uretero-pyelo-anastomosis did not reestablish the urinary flow completely, be- 
cause a lumbar fistula developed eight days later. 

3. Ureteral catheterization opened a channel for the urine, for the lumbar fistula 
healed under this treatment. Besides, the analysis of the urine from the affected kidney 
collected for a period of twenty-four hours showed that the kidney had no functional value 
whatever. 

4. Nephrectomy demonstrated that although the ureteral lumen was absolutely patent 
in its entire course, from its origin at the pelvis to its new ureteral orifice, nevertheless it 
flowed incompletely through the ureter because the pelvis was found full of urine at the 
second operation. 

The patient left the hospital on January 29, 1905, cured. Tlie specimen is preserved 
in lily private collection. 

Case 3. — Tiiberculosis of the Higlit Kidney: Recognised iy the Luys' Separator and 
Confirmed hy Direct Ureteral Catheterisation. 

A woman, aged twenty-eight years, was brought to me on November 30, 1905, by 
Nogues, who. wrote the following report of the case: 

She had complained for over a year, of frequent urination, with pain and slight 
hematuria at the end of the act. The urine, examined by Nogues, contained numerous 
tubercle bacilli. Vesical capacity 80 c.c. She voided six to eight times during the night. 



('ATM i'yii;i;i/A'i'i(».\ oi' tiik ri;K'i'Ki;s 281 

Tlici-c was iin jiaiii in llic kidiicv ri'^iinii, nui' any incir;isc in llic si/.c <<{' the l<iiini'y. I'imlo- 
vcsical scpaial inn, nimlc by Noyiirs will: l.iiys' separator, hust: tliis picture: On the left, 
ricar urine; on IIh' li^lil, more al)nn(lan1 urine, paler, lurliid, and tubercle bacilli pix-soiit. 
Indirect cysloscoiiy showed a ninanal liladih'r. 1 1 ow i'\ cr. llie riylit ureteral orifiee is not 
sullicienlly visilile (o nu', 1o ni;ike il woilii while (u atleni|il ral liel eri/.at ion. ( 'onscfjuent ly the 
jialiiud was taken In laiys, who easily inli'odui'ed a eathelei' inio the ri;;lit urelei- with his 
direct cystoscope, in the presence uf the writer. 

A flow of pus showed I hat the catheter had penetrated into the purulent poclvct of the 
rii;li( kidiM'y, and thus had accomplished its object. Subsequently, the patient was oper- 
ated ou at Necker Hospital, and recovered rapidly witliout untoward incident. Nephrectomy 
revealed three pus cavities, thus fully verifying the diagnosis made by the cystoscope and 
catheter. 

Case 4. — Eight Pyonephrosis and Amite Cystitis: Urinary Scimration Impossible, Excrpt 
by Direct Ureteral Catlieterisation. 

I was called upon to cathcterize the ureters in a woman, aged thirty-five years, in the 
service of Hartmann, at Lariboisiere Hospital, on April 17, 190o. She showed clinical 
symptoms of right pyonephrosis. The kidney was palpaljle, and the right ureter was also 
felt very much enlarged. But inasmuch as the left kidney was also palpable, but to a 
lesser degree, segregation of the urines seeined indicated. The symptoms of cystitis were 
so acute, however, that an cndovesical separation of the urines could not be considered. The 
urine was turbid, with a purulent precipitate, and in addition, the urine was voided every 
fifteen minutes, with hematuria every two or three days. Catheterization by means of the 
indirect (prismatic) cystoscope was also out of the question, because of the very small 
vesical capacity. 

With the aid of the direct cystoscope, I catheterizcd the riglit ureter in a few minutes 
without any difficulty; the endoscopic tube having been withdrawn, the right ureteral cath- 
eter remained in situ, and a Nelaton catheter was introduced into the bladder. Tliis sepa- 
ration of the urine gave the following results: 

The ureteral catheter which drained the right kidney gave an absolutely purulent 
milky white fluid; while the catheter in the bladder, which collected the urine from the 
left kidney, produced urine that was bloody, but not quite so thick as the urine from the 
right side. 

Case 5. — Uretcro-pyclo-a nastomosis : Direct Catlicterizatioii of the Operated Ureter 
Showed Distention of the Pelvis. 

A woman, having ])een subjected to a left uretcro-pyelo-nnnstomosis by Robino:ui. in 
the service of Tutfier, for symptoms of uronephrosis, later developed a lumbar tislrda. On 
May 2, 1905, in order to correct the improper drainage of the new ureteral mouth, Rolnneau 
asked me to catheterize the left ureter. Direct catheterization was performed easily, and 
demonstrated that the pelvis was considerably dilated and had a capacity of about 150 e.c. 

Case 6. — Attacks of Left Hydronephrosis: Catheterization of the Left Ureter Sitff- 
gcsting the Presence of a Ureteral Calcuhis. 

A woman, aged twenty-five years, entered tiie Tenon Hospital, in the service of 
Rochard, in March 1905, complaining of violent, painful attacks in the left hypochondrium, 
Avhich recurred frequently at intervals varying from four to fifteen days. These attacks 
first appeared four years previously. During the crises. :r inass appeared at the left 
hypochondrium coincident with a considerable decrease in the (piantity of urine passed. 
A preliminary examination by direct cystoscoiiy, on March 11, showed the right ureteral 
ejaculations very clearly, but on the left side, on the contrary, although the orifice was 
distinctly visible, not a, drop nl' urine was ejaculaleil. 

The left kitluey was clearly felt ou bimanual palpation; it was easily reducible and 



282 CYSTOSCOPY AND URETHROSCOPY 

also quite paiuful. On Marcli 24, after many attempts at catheterization of the left side, 
a ureteral catheter No. 6, was easily introduced, with some interruptions at first. With 
the aid of a stylet inserted into the lumen of the catheter, it penetrated ^ far as the 
pelvis J the capacity of the latter proved to be about 25 c.c. While the catheter was 
being withdrawn, a sensation of friction was distinctly felt; this justified the suspicion 
of a ureteral calculus. The patient was sent to the radiographic department, but un- 
fortunately, the case could not be followed up thereafter. 

Case T.—^The Bight Kidney Alone Clinically Affected: Intravesical Separation and 
Catheterization of the Ureters Shoiv Both Kidneys Affected, a Contraindication to Bight 
Nephrectomy. (Courtesy of Lapointe.) 

M., a woman, aged thirty-two years, was referred to Lapointe, at Tenon Hospital, 
on May 10, 1905, by Barbellion, who had been treating her for several months for cystitis 
and enlargement of the right kidney. The patient had had trouble with her right kidney 
from infancy, but apart from these symptoms, she had not had any previous serious ill- 
ness. Several cervical scars, however, resulting from an old suppurative adenitis, were 
observed. It was also noted that her father had died of pulmonary tuberculosis at the 
age of forty. 

During pregnancy, eighteen months previously, she complained of frequent and pain- 
ful micturition. At the same time, the pains in the right kidney increased considerably 
and the patient noticed a swelling on the right side. This mass alternately increased and 
decreased coincidently with the increase and decrease of the painful manifestations. From 
that time on, the urine became turbid, but without any hematuria. 

Late in 1905, Barbellion began to treat the bladder, which was very sensitive, by 
instillations of silver, and subsequently with guaiacol oil and gomenol. Under this treat- 
ment, the urinary frequency and the pain diminished, but the kidney remained large and 
sensitive. 

When she entered the hospital, the urine was turbid and purulent, but without blood; 
frequency every hour. The bladder was extremely sensitive to contact and to distention. 
Its capacity was only about 30 c.c. On palpation, the right kidney was found as large as 
both fists, lowered in position, irreducible, painful on pressure and fluctuating. 

The vesical portion of the right ureter Avas thickened and painful on vaginal e;xamina- 
tion. The left kidney was not palpable. To complete the diagnosis and determine the ad- 
visability of right nei^hrectomy, Lapointe employed the Luys segregator, on May 16, 1906. 
The instrument was badly tolerated by the bladder, because of the bleeding and the small 
bladder capacity of 30 to 35 c.c. Nevertheless, a quantity of urine was collected, suffi- 
cient for the chemical examination, which was made by Carrion, with the following findings: 



RIGHT KID 


NEY 


Quantity 


3.06 c.c. 


Urea, per liter 


3.20 gm. 


Chlorides 


4.68 " 


Freezing point 


0.54° 




Microscopic 



LEFT KIDNEY 


3.03 


c.c. 


2.56 


gm. 


4.68 


i e 


0.52° 





Red blood cells, very numerous. Eed blood cells very numerous 

Leucocytes, mostly polynuclear. Leucocytes much less abundant 

very numerous. 

Bacteriologic examination for tubercle bacilli, negative; the urine of both kidneys con- 
tains bacteria, some Gram positive and others negative. Most of them are diplostreptococci 
and microbes which appear to be coli bacilli. Two guinea pigs inoculated on May 17, with 
the right kidney urine, gave a negative reaction to tuberculosis. 



CA^rii I'/i'i'iKi/ATiox (»i' 'I'lii'; ri;i':'i'i';i;s 



283 



AVc were, tlicicrdrc, |ii(ili;i 1 il y ili';iliii;^ with ;iii nidiniiiy inrrrtnMi; lnif llic cinlnvcsical 
S;0|)ar:iti(ill of llir lllini' ill.lirulcd (lllll tlir Irl't kidney, wliirli \v;iS in.t riil;ii'-c(|. mid was 
clinicalh' imnnal, iicvrrl liclcss, ciiiittcd sli;;lMly (dniidy iiiinc and tlial its I'atc of (diiiiiiiat ion 
\vas sliiwcr tlinn tliat of the li^lit kidney, wliiidi was idinienlly afrocted. 

In Older to coafiiiu tliesc unoxpectod data, Lapoiiite attempted tlic nietliylenc l.liio test 
with ureteral catheterization, aiul used the Luys' direct view cystoscopc fur this purj)OHe. 
After two fruitless trials, Luys was called in on May 2(). To obtain relative tolerance of the 
bladder, Lapointc had injected scoiwlamine-morpliijie an hour before the examination, using 
this solution: 

Scopolamine biomohydrate ^/> nijj. 

Morphine ('Idorliydrate 1 eg. 

The cystoscopc sliowed that the l)laddcr was considerably affected with fungous growths 
which bled on the slightest contact. The right ureteral orifice was seen in the midst of the 
fungositics and readily catheterized with a No. 8 catheter. It was much more difficult to 
reach the left ureteral orifice, for at this point the bladder bled profusely. However, the 
mucosa was thoroughly dried by the direct application of adrenalin and then the left ureteral 
orifice was seen, hidden at first, by a fold of the mucosa. To see it well it was necessary to 
flatten down the mucosa with the extremity of the cystoscopic tube, and a No. 7 catheter 
was then easily introduced. 

As soon as the catheters were introduced into their respective ureters, a reflex polyuria 
was produced; the urine from both sides was cloudy. Previous to the ureteral catheteriza- 
tion, methylene blue was injected subcutaneously ; the ureteral catheters were left in situ 
for two hours and during this period the methylene blue was being eliminated in the form 
of chromogen, as follows: 

RIGHT KIDNEY LEFT KIDNEY 

First hour Nothing Nothing 

Third half hour Distinctly green tint Green tint much less marked 

Fourth half hour Not more pronounced than on right side 

Not more pronounced 

The urine passed by the patient was first examined for methylene blue seven liours 
after the injection and the total elimination persisted for about forty-eight hours. The 
left kidney then eliminated less chromogen than the right kidney. The study of the methy- 
lene blue elimination in both kidneys, by the aid of ureteral catheterization, is in full ac- 
cord with the results of the chemical analysis and of cryoscopy made on the separated 
urines. 

Conclusions. — Segregation of the urines demonstrated that the left kidney, whiili was 
thought to be healthy, was also diseased, and that its functional value was even inferior to 
that of the right kidney. The baeteriologie examination, negative as to tuberculosis, sug- 
gested a diagnosis of right hydronephrosis, the kidney having been infected probably by au 
intercurrent cystitis; also a secondary pyelonephritis of the left kidney. 

Tlie pathologic condition of both kidneys was a distinct contraindication tu n('(ihrcc- 
tomy of the right kidney, and limited surgical intervention to nephrostomy; but the pa- 
tient left the hospital on learning that her right kidney could not be removed. 

REFERENCES 

iBull. et. mem. Soe. de (diii'. ile Paris, l!l05, session of INlarcli 1, llHii;, p. I'll. 
-Legueu : Du cat heterisme de I'uvetere a travers la vessio ouverte. Press, med.. A]iiil in. 
11)07, p. 226. 



PLATE XYlIl 

Fig. 1. — Fhosphatic calculus of the bladder pocketed in the inflamed 
mucosa. 

Fig. 2. — Fhospliatic calculus of the bladder. 

Fig. 3. — Tuberculous ulcerations of the bladder seen with, the direct vision 
cystoscope. 




Fig. 1. 





Fig. 2. 



Fig. 3. 



PLATE XVIII 



(lATII KTKIM/ATIOX OK T 1 1 I', IIIKTKUS 2S5 

CHOICE OF METHOD IN URETERAL CATHETERIZATION 

IlavJii^' lliiis cxaiiiiiKMl successivclx- .•ill llic niclliods and x>i"Ocediii"os 
for lU'eteral calliclcrizatioii, it is a\'('II Io iii(|uii(; as to wliicli motliod 
is to be ft'ivcMi prcfVi-ciicc. Tt is cNidciil that catlieterization is to be 
perforiiu'd cillici' willi (rn'cci oi' iiidii-cct A'isioii cyslosfopy. Tliese two 
methods should iiol he set ii)) one a,^ainst tiu; ot]!(!r, as rivals, inasniiieli 
as eac'li lias its own s]HH'ial indieations; one slionld supplant the other 
under certain circumstances. 

Indications for Direct Vision Cystoscopy in Ureteral Catheterization 

This method seems to be the inelhod ol; choice and should l)e pre- 
ferred above any other under the followin<2,' principal conditions: 

1. For Catheterization of a Normal Kidney. — When there is a spe- 
cial indication for obtaining exact knowledge of the condition of the 
ureter or of the pelvis of a Icidney thought to be normal, it seems evi- 
dent that only the direct vision cystoscope should be emx^loyed for 
catheterization. 

We shall consider further on, the real and absolutely certain dan- 
gers of infection which arise in ureteral catheterization with the in- 
direct method. These dangers are, on the other hand, reduced to a 
minimum, if not obviated entirely, with the use of the direct vision 
cystoscojDe. 

With this method, the ureteral catheter emerges from the sterilizer 
and directly passes into the ureter, coming into contact only with the 
aseptic fingers of the surgeon. The only possible clanger is found in 
touching the infected vesical wall with the catheter, if the hand is not 
exjDerienced ; but when the end of the cystoscopic tube is directly in 
contact with the ureteral orifice, it is a simple matter before introduc- 
ing the catheter, to touch up the vesical wall surrounding the ureteral 
orifice with a 2 per cent solution of silver nitrate, thus obtaining momen- 
tary sterilization of the area. It is thus made evident that the dangers 
of infecting a normal kidney, if not absolutely nil, are at least reduced 
to the minimum, wh(>n oy)erating with the direct vision cvstoscope. 

2. To Estimate the Renal Function When the Separator Can Not 
Be Used. — The use of the separator is sometimes impossible; for in- 
stance, in the presence of anatomic anomalies, such as the two cases 
that I have observed, in which the inferior wall of the bladder was 
destroyed by vesicovaginal fistuhu. This is also true in advanced preg- 
nancy, or in cancer, oi' libroma ol* tlic uicius, etc. Ijikewise in cystitis 
Avhicli is so pronounced lliat the exlrciiicly sensitive bladder contracts 
violently and pr(>\'en1s the I'egular a])pli('alion of the instrument. 



286 CYSTOSCOPY AND URETHROSCOPY 

In tliese cases ureteral catlieterization should be performed only 
with the direct vision cystoscope. First, because the vesical- capacity 
is very small; and second, because the difficulty of obtaining the re- 
quired transparent bladder medium makes indirect cystoscopy almost 
impossible. 

What a difference there is in operating A\itli the indirect cysto- 
scope, when pus and blood constantly obstruct the visual field, and on 
the other hand, with direct cystoscopy, with which, after tamponing, 
the operation is performed on a dr}^, clear mucosa, upon Avhich one 
can work with security, with system and Avitli success! 

In a particularly difficult case, I obtained a splendid result. In the 
service of Souligoux, at Tenon Hospital, I saw a young woman, aged 
twenty-four years, who had a large tumor on the riglit side and seemed 
to be suffering pain on the left side. The urine was extremely bloody, 
the vesical capacity Avas 100 c. c, and it Avas almost impossible to obtain 
a transparent medium. NotAvithstanding these difficulties, on NoA'-em- 
ber 8, 1907, I AA^as enabled to catheterize the left ureter, the only one 
Adsible, in the presence of Lagane, intern of the hosi)ital. 

Gauthier, of Lyons, Avas also able to locate and catheterize one 
ureter in a tuberculous bladder AAdiich Avas completely ulcerated and 
bleeding on the slightest contact, and Avith a capacity of 40 c.c. In an- 
other case Gauthier found it possible, Avitli my direct cystoscope, to 
catheterize a ureter the orifice of AA'hich had prolapsed and taken the 
shape of a cornucopia. In his OAvn Avords : " It can be said Avithout exag- 
geration, that these Iavo patients OAve their liA^es to the direct vision 
cystoscope." 

3. Apart from these striking cases, it seems that the direct Adsion 
cystoscope, generalh^ speaking, is by far preferable in Avomen, to the 
indirect cystoscope. The direct introduction of a catheter into a female 
ureter is the simplest and easiest matter; it takes but a fcAV seconds. 
Double catheterization of the ureters is also much easier with the direct 
than with the indirect method. 

Quoting Ferron: "EA^en the manipulation of the catheters is sim- 
plified; changing the catheters so as to find one that Avill enter the ure- 
teral orifice, is much more rapidl3^ accomplished than it can be done 
Avith the indirect cystoscope. Another real advantage is the diversity 
of form of the catheters that may be used. With the indirect method 
only cylindrical catheters are employed. LaA^age of the pelvis, for 
instance, is greatly facilitated by the use of catheters having a funnel- 
shaped end. The tip of the syringe adapts itself to the funnel-shaped 
end hermetically. The quantity of fluid injected and consequently the 
I)elAdc capacity, can be exactly determined Avitli cylindrical catheters; 



CATIIK/rKIMZATlOX Ol" 'I'lIK I ' iii'/noiis 287 

tliis osiiiiKitioii hccoiiics a iiiiicii more dclicalc niallcr. I'jViiafd's con- 
ical calliclcrs, llic distal calihcr of w liicli iiH'asiircs 12, 11), 1-4- Ciiarricfo, 
liavo f2,ivon us oxccllont service." 

4. AVitli (liivcl vision cystoscopy, catlieters of relatively lar^-e cal- 
ilx'i- II]) to No. IT) CMiarriere, can he iiisert(Ml as far as tlie kidney. Tlieii- 
larg-e wide ruimcl can not ])ass tliiT)ii,i;'li tlic iiai-iow canal oi' llic indirect 
cystoscoi:)e, an advantage wliicli Facilitates co])ious lavage hy ])ei-init- 
ting tlie use of a large syringe. 

5. In a normal Ijladder and under noi'nial circumstances, a cathe- 
ter manipulated through tlie indirect cystoscope may not l»e ahle to 
enter the ureteral orifice hecause it impinges on the wall or slides over 
it. Nitze himself showed me an instance of this kind in Berlin. In 
these cases, on the other hand, direct vision cystoscopy rarelj^ fails. In- 
deed, the catheter, which is kept rigid h}^ the stylet can penetrate the 
ureteral orifice much more readily than with the indirect cystoscope. 

All that is required is to isolate the orifice within the lumen of the 
cj^stoscopic tube, and perhaps to press the border of the tube against 
the ureteral orifice; thus the ureteral meatus will protrude into the 
tube and however small it may be, a catheter will usually penetrate into 
the ureter. 

I employed this procedure on November 7, 1907, at Saint Louis 
Hospital, in the service of Beurnier, in a Avoman with symptoms of 
hydronephrosis, Avith a very small ureteral orifice. By the aid of this 
method, catheterization was easil^^ accomplished. 

6. In inflamed and hemorrhagic bladders ureteral catheterization 
with the direct vision cystoscope should be preferred. Jean Ferron has 
emphasized this jDoint very strongly in an interesting study^ on ureteral 
catheterization by direct vision cystoscopy.. He says: 

"When the bla(hler does not tolerate the necessary 80 c.c. of fluid 
for indirect cystoscopy, some authors, hardly mentioning Luys' tube, 
frequently advise .surgical intervention. That is, exclusion of the dis- 
eased kidney, luml)otomy, nephrotomy, ureterostomy. This method of 
procedure is suggested in some of the most recent publications. Just 
a few lines are devoted to the suggestion that direct vision cystoscopy 
is indicated when 'cystoscopic catheterization is rendered impossible 
by the unfavorable condition of the bladder.' 

''Nevertheless this method has great advantages. The fact that 
it has been neglected seems to us unjust for more than one reason. * * * 

"In numerous instances of intolerant bladder, with a capacity less 
than 80 c.c. thus rendering cystoscopic examination inipossil)le, Ave liaA'e 
been able to catheterize successfully Avith Lii>s' cystoscope. A detailed 
description of these cases need not h<? gi\-en here: suffice it to say they 



^OO CYSTOSCOPY AXD rEETHROSCOPY 

were observed by Poiisson and liis students. AVe sliall relate the his- 
tory of one very interesting case: *. 

"L., aged thirty-five years, postal clerk, consulted me in February, 1912, for polla- 
kiuria and hematuria. A brother and sister had died of tuberculosis. 

"In 1902, while a sergeant major of chasseurs, in previous good health and without 
genital disease, he suddenly developed a right orchiepididymitis, following a trauma. This 
lesion increased gradually, and in 1903, one year later, he noticed a painless induration of 
the left epididymis. Discharged from ser^-ice, he went home and for a long time did not 
show any sjnnptoms other than the abnormal size of Ms epididA-mes. In December, 1910, 
after a bicycle ride he noticed his shirt was blood-stained. In September, 1911, his urine 
was cloudy, he micturated once during the night and the urine left a deposit in the glass. 
Urinary frequency increased. Separation of the urine made by a specialist showed bloody 
urine from the left side and nothing whatever from the right side. According to the 
patient 's statement the right catheter was found clogged by a blood clot when it was with- 
drawn and examined. The physician made no attempt to interpret the result of the test. 
Tlie pollakiuria increased to such an extent that the urine was voided almost continuously; 
in this condition he was referred to us. 

''General condition is fair. A superficial examination does not reveal anything but 
two enormous epididymes. The renal regions are not painful; pressure on the hypogastrium 
is slightly painful. Palpation of the ureteral points and Pasteau's points is negative. The 
urethra is free and painless ; the prostate is large and uneven ; urine very bloody. In spite of 
a previous injection of stovaine, it is impossible to introduce into the bladder more than 
20 to 25 c.c. of fluid. Indirect cystoscopy had to be given up. 

' ' Luys ' tube passed easily. We found ourselves in the presence of a rare form of 
cystitis. The vesical cavity is occupied by a gray, fringed, denticulated false membrane, 
resembling felt, which covers the entire mucosa. A ureteral ejaculation indicated the site 
of the left ureteral orifice, and a No. 8 catheter was introduced as far as the renal pelvis. 
Analysis of the separate urines collected during three and a half hours (Labat) is as follows: 



Quantity 

Urea j^er 1,000 c.c. 

Urea completely eliminated 

Chloride of sodium per 1,000 

c.c. 
Chloride of sodium com- 
pletely eliminated 
Albumin 
Blood 



LEFT KIDNEY 

14 C.c. 
12 C.C. 
11.5 c.c. 
7.60-23.60 gm. 
0.706 gm. 

6.40 - 8.40 gm. 

0.220 gm. 
8.-4. gm. 

All over the field. Many 
blood elements, leucocytes 
predominating. No m i - 
crobes. 



BLADDER 

(6.5 c.c. 
3 c.c. 
3 c.c. 
22.10-12.60 gm. 
0.219 g-m. 

8.90-7.90 gTQ. 

0.205 gm. 
9. - 9. gm. 

All over the field. Blood 
elements, leucocytes predom- 
inating. Few easts and 
many bacilli. 



"Two days later, the right ureter was catheterized. The catheter was arrested at a 
point 12 centimeters from the orifice and only a few drops of bloody urine were recovered. 
Another catheterization of the same side gave the same result. So then, all of these 
examinations showed a diseased condition of the right kidney, although the microscope did 
not reveal any tubercle bacilli. The results previously obtained by the urinary separation 
were thus confirmed. At that tinio, the secretion of tlie right kidney had already become 
considerably diminished. 



CATHETEltlZATlOX OF THE mETERS 289 

"Nephrectomy snjigested itself at once. Before operating, liowever, we attempted 
to clear the bladder of tlic gray fringed pseiidomembranes which covered it. Tliis was ac- 
complished in several sittings by direct cystoscopy using a forceps devised for endovesical 
manipulations. During this period the patient for the first time expelled a considerable 
quantity of false membrane between the sittings. These membranes contained very dense 
groups of Koch bacilli. This fact was all the more interesting because the microscopic ex- 
aminations were negative and guinea pig inoculation of the separated urines also proved 
to be negative. 

''On March 22, 1912, when the bladder had been cleared of all the false membranes, 
a lumbar nephrectomy was performed and followed by a right epididymectomy. The renal 
j)arenchyma was almost completely destroyed and presented large cavities which communi- 
cated with the pelvis; the latter with very thick walls, was continuous with a ureter whieli 
was considerably narrowed at certain points. The postoperative history was uneventful. 
The patient left the hospital on the twenty-seventh day, fully recovered. He has remained 
under treatment since then for his vesical lesions. 

''In tliis case, distention of the bladder being absolutely impossible, 
LiiYs' cystoscope helped its to make the diagnosis of the diseased side 
and assured the integrity of the opposite organ. This was done without 
having recourse to comiDlicated oi3erative measures usual in such cases. 
Thanks to direct cystoscoj^y, we found and treated a rare form of tuber- 
culous cystitis, successfully catheterized both ureters and determined 
the proper treatment to be adopted. 

"In conclusion, we do not pretend that Luys' instrument and the 
indirect cystoscope are rivals. We do not purpose to minimize the 
innumerable services rendered by the Albarran deflector. We have 
tried to show, however, that in addition to the classic method, uni- 
versally used, there exists a method of catheterization that is not suffi- 
ciently well known. One of its great advantages is a much more thor- 
ough asepsis. In an inflamed bladder where a kidney infection is to be 
feared, the metallic tube (Luys) is to be preferred because it is more 
truly surgical in its simplicity. Its employment is far more practicable 
in women, because of the facility of manipulation, and the advantage of 
a quick change of the catheters, when it is desired. We do not hesitate 
to repeat Luys' assertion that direct vision cystoscopy is the method 
of choice in the female. 

"Its advantages are perhaps not so striking in the male. Never- 
theless we have used it for many months without occasion for regret. 
A urethra with a caliber less than normal, or an extremely obese patient, 
were the only obstacles to this method of examination. 

"Lastly, we repeat that in difficult cases in which the indirect cys- 
toscope has failed, before resorting to bloody oiDerations, direct vision 
cystoscopy should he attempted, but only l;)y a surgeon who has had 
experience with Luys' tube. In many instances it will give him im- 
portant information, without subjecting the patient to the slightest 
risk." 



290 CYSTOSCOPY AND URETHROSCOPY 

7. In a bladder with trabeculations or with diverticuli, the search 
for the ureteral orifice is often extremely simj)lified by the direct cys- 
toscope. Ferron reports- the foUoAving interesting case apropos: 

"In a female patient in the service of Pousson, we searched in vain for the left ure- 
teral orifice at its normal site and all around it; suddenly, thrusting the extremity of the 
tuloe into a very narrow diverticulum, we saw the ureteral orifice and catheterized it easily. ' ' 

It can be readily seen that if the indirect cystoscope had been used 
in this case, the diverticnlnm in which the ureteral orifice was found, 
would have remained in the dark, undiscovered. The superiority of 
the direct vision cystoscope is thus very evident. 

8. A final advantage of direct catheterization is found in the fact 
that we can better see and demonstrate to assistants tliat the catheter 
has really entered the ureter and has not merely slipped along the sur- 
face of the mucosa. Indeed, by manipulating the tube properly, the 
entire circumference of the catheter can be seen ; we can also determine 
that it is completely surrounded by mucosa and that it stands out promi- 
nently in the bladder, like a flagstaff dug into the ground. 

Indications for Indirect Cystoscopy in Ureteral Catheterization 

There are two principal indications for the employment of the in- 
direct c3^stoscope in ureteral catheterization: 1. In obese and asthmatic 
(congestif) males. In these patients the inclined position is not easily 
maintained, and again, the bladder does not distend itself well on ac- 
count of the abdominal plethora. In stout females with marked gen- 
ital prolapse, distention of the bladder in the inclined position is 
likewise impossible. It is preferable to use th« indirect cystoscope in 
these casse. 2. In males, with the urethral meatus or the urethra itself 
of a relatively small caliber, Avhich does not admit the tube of the direct 
vision cystoscope. 

SiTBSEQUEXT StEPS IX UrETEPwAT. CATHETERIZATION 

As soon as the catheter is properly placed and the cystoscope 
removed, a recipient (sterile test tube) is placed immediately under- 
neath so as to collect every drop of fluid; not a single drop of fluid 
should be lost, because the ureteral catheter may have drained a renal 
retention cavity, the presence of which and the measurement of its 
capacity are always important to know. 

AVhen everything has progressed well, some time is allowed to 
pass in order to collect a sufficient quantity of urine; and when this 
has been done, the catheter may be removed. But in the meantime 
it is highly imiDortant to profit by the presence of the catheter to deter- 
mine the pelvic capacity; aj)art from the important information which 



CATIIKTKIM/A'I'IOX oi' '1' 1 1 K UKETERS 291 

can lliiis Itc ,i;aiii(Ml, llic aiilis('|)1i(' soiuiions, lil<(' llic l:l()i)0 silver 
iiiii'aic. Tor ('xaiii])l(', have the ,i;r('al N'aliic ol' cIcai'iii.L;' ili<' pelvis and 
ui'cici' of all the |)()ssil)l(' coiilaiiiinalioiis hi'oii^lit in by llic lip of llic 
callielci'. If lliis is done, accidcnls due lo llie catliolcrization arc very 
rarely seen. 

Tlie palienl sliould lake certain precautions after catheterization. 
Tnnncdialely lliercafler, lie sliould i;o to hed for t\\ enty-four liours and 
drink water copiously. He should take two grains of urotroijin in twen- 
ty-four hours. With these indispensable pi'ccaulions, ureteral catlieter- 
izalion can he accomplished without any risk of injury to llic palienl. 

REFEREISrCES 

iFcrron: Jour. cl'Uiol., 101?., iii, p. 65. 

^Ferron: A piopos du cntlietcM'isme ureteral, Jour. d'Urol., December, 1912, Obs. XIX. 

DIFFICULTIES, ACCIDENTS, AND ERRORS IN URETERAL 

CATHETERIZATION 

Ureteral catheterization can be rendered imjDossible by many cir- 
cumstances, the principal being the following: 

1. Difficulties Inherent in Indirect Cystoscopy. — These have al- 
ready been studied (see page 189) and will be mei'ely enumerated at 
this time, as follows : narrow meatus, urethral stricture, spasm of the 
meml)ranous urethra, hypertrophy of the prostate, cystitis, very small 
vesical capacity, etc. 

2. Impossibility of Locating the Ureteral Meatus. — Unfortunately 
there are numerous conditions in which the ureteral orifice is practically 
invisible. In pronounced cystitis, with edema and inflammation of the 
vesical mucosa, the ureteral orifice may be completely hidden among 
the edematous masses, thus rendering its discovery almost impossil^le. 
On the other hand, in prostatics, the orifice is displaced, even hidden 
behind the prostatic swelling. In changes affecting surrounding organs, 
e.g., uterine cancer, fibroma, pregnancy, it may be very difficult to find 
the ureteral orifice and sometimes even impossible to see it at all. 

3. The Ureteral Orifice May Be Small. — In the same manner that 
a urethral meatus is sometimes too small for the introduction of a 
sound, the ureteral meatus is likewise occasionally so snuill that the 
fmest ureteral catheter can not be introduced. AVhen, however, the lips 
of the ureteral meatus are narrowed congenitally, and not through 
inflammation, they can be treated in the same manner as the urethral 
oiifice. First Ave attem])t to introduce a small Xo. 5 catheter with an 
olivary tip; this is followed by a No. 6 catheter which is forced gently 



292 CYSTOSCOPY AiSTD URETHROSCOPY 

into tlie ureteral orifice. In these cases, it is always best to use cathe- 
ters with an olivary tip. ^ 

4. Inflammation of the Ureteral Orifice. — This is very often due to 
a pathologic change in the corresj)onding kidney and to a p^^onephrosis. 
It may very often prevent the introduction of a catheter because ulcera- 
tions are found around the ureteral orifice which bleed by the contact 
with or passage of the catheter. 

5. The Arrest of the Catheter a Few Centimeters from the Mea- 
tus. — This obstruction is relatively frequent and takes place about two 
to four centimeters from the meatus. There are various causes. In the 
first place the ureter is narrowest at this point; secondl}^, the ureter 
bends across the bifurcation of the pelvic blood vessels at this point at 
the level of the promontory. 

In the presence of these difficulties, certain expedients must be re- 
sorted to ; one of the most useful is to vary the flexion of the thighs over 
the pelvis, thus increasing or diminishing the amount of flexion. In 
this way, the introduction of the ureteral catheter can be facilitated. 

6. The Ureteral Catheter Does not Drain. — Unfortunately, this is 
not a rare occurrence and may be due to several causes; one of the prin- 
cipal causes being that the extremity of the catheter is in a faulty posi- 
tion, having been introduced too far into the renal pelvis. In such 
circumstances it is advisable to withdraw the catheter slowly for 
about two or three centimeters, and the flow will be reestablished. 

Occasionally in spite of this procedure, the catheter still does not 
drain. We must then exercise patience and wait ten or fifteen minutes. 
At the end of that time droplets of pus or tiu}^ blood clots are seen 
emerging from the catheter, thus exj)laining the cause of the previous 
failure of drainage. 

In still other cases, in spite of all one's patience, the urine persists 
in refusing to flow. An attempt should be made to clear the catheter 
of possible obstructions, by injecting a small quantity of fluid into its 
interior. This expedient should be utilized only as a last resort, because 
the chemical analysis of the urine w^ill be changed as a result of the 
fluid injected. The urinary secretion is thus diluted with a quantity of 
water which it is very difficult to estimate properly. 

7. The Catheter Drains Too Much. — This is not properly speaking 
a serious disadvantage, but it is well to know how to interpret this 
polyuria projDerly. It may be due simply to the evacuation of a hydro- 
nephrosis; the exact quantity of the flow should be measured and re- 
corded. 

It may also be due to the renal irritation produced by the intro- 
duction of the catheter. A very simple method of differentiating these 



CATIIKTKKI/A'IIOX oi 'llll': t IIK'IKIIS 293 

coiidilioiis ;iii<l lliii.- iii;iUiii,t;' a correct dia.^iiosis, is lo study tlic cliar- 
acter of the llow; wlicii tlic ovacualioii lakes the roim of a jet, or is a 
coiitiimoiis llow without iiilurinis.sion, it is inoi'e than ])i'ol)ahh' that nv<' 
ai'i' (h-aliiii;' \\\\\\ the evacuation of a liydi-ouejjhiosis. When, to tlie 
conti'ai'y, tlie ureteral ejaculations arc decidedly i-liythuiic, with inter- 
vals duriii,*;- ^\■hicll urine does not llow, a ph_\siologic excitation of tlie 
kidney nuist l)e the canse. 

8. The Flow Is Blood Stained. — This is also a i-elatively fieciuent 
occurrence in catlieterization. It may be said to be constant, because 
microscopic examination of catlieterizecl nrine invariably reveals some 
blood cells. Their presence is easily explained; the catheter in passing- 
through the nreteral interior necessarily injures the ureteral mucosa 
to some degree and thus usually produces a slight hemorrhage. This 
may be negligible or simply microscopic; on the other hand, it may 
be nuicli more important especially when the kidneys do not function- 
ate steadily and when the renal pelvis is not properly cleansed by a suf- 
ficient quantity of urine. 

Accidents Associated With Ureteral Catheterization 

The accidents which may occur in connection with ureteial cathe- 
terization are either mechanical or infectious in character. 

Mechanical accidents are relatively very rare. Perforation of the 
ureter has been reported, but this is an extremely unusual occurrence. 
Infectious accidents are more serious and more fre((uent. 

Infection of a Healthy Kidney by the Ureteral Catheter. — A ure- 
teral catheter introduced through the indirect cystoscope in an infected 
liladder filled with fluid may carry joathogenic germs into the renal 
pelvis and thus bring about an infection in a previously healthy kidney. 

This is an undeniable and undoul)ted fact, and it has been observed 
by numerous authors. This accident may result in spite of copious and 
repeated irrigation of the bladder. It is a fact well known to all who 
practice indirect cystoscopy, that even after the bladder has been thor- 
oughly ii-rigated and the lluid comes out perfecth' clear, the vesical 
nmcosa is not absolutely clean. This is mad(^ evident by the numer- 
ous impurities that can be seen floating in the fluid through th(^ lenses 
of the cystoscope. The catheter coming in contact with this lluid, be- 
comes infected not only on its external surface, but likewise in its 
interior, which is far more seiious. In this wav the catheter, soiled 
with inii)urities "intns et extra," becomes a ^xM'fect carrier of microbic 
elements which can and ina\' infect the pelvis and the hidney. 

This is fully confirmed in a report of a typical case by Rafin, 
of Lyons,^ who found that spcrniafnznirls icere evacuated iliroiir/h a 



294 CYSTOSCOPY AND URETHROSCOPY 

catheter inserted in a ureter! ''In a patient who had to be anesthetized 
because of the limited capacity of the bladder, I found spermatozoids 
in the urine evacuated through the ureteral catheter, although a thor- 
ough washing of the bladder was previously effected. It is probable 
that the patient emptied his seminal vesicles during the struggle in the 
early stage of the anesthesia ; the sperma Av^ere carried into the bladder 
by the cystoscope and the vesical fluid containing a considerable quan- 
tity of spermatozoids in suspension, had thus filled the ureteral cathe- 
ter with them." 

But this is not all: Apart from the fact that the ureteral catheter 
may become a carrier of microbian elements capable of infecting the 
pelvis and kidney, in a direct manner, as just mentioned, infection of 
the kidney may take place indirectly as well. When the catheter passes 
into the ureter, it forces the ureteral valve, — the "guardian of the ure- 
ter;" an ascending infection may be produced as a result of this forcing 
of the ureteral valve. 

In these circumstances, there is a reflux of the infected vesical fluid 
into the ureter. Margulies- has stated: ''We have occasionally noticed 
the reflux of the boric solution from the bladder into the ureter, and its 
subsequent elimination through the ureteral catheter. Casper was the 
first to call attention to this fact; for proof, he injected coloring sub- 
stances into the bladder and immediately afterward these substances 
were eliminated through the ureter. 

[The editor observed a case but recently which gave the follow- 
ing confirmatory phenomena: The patient was taking methylene, blue 
internally and the urine was colored deep green. A kidney lesion was 
suspected and the bladder Avas filled with oxycyanid solution prepara- 
tory to cystoscopy (indirect) and catheterization of the ureters. When 
the catheters were inserted, it was found that the left catheter was 
draining green urine, and the right was draining white fluid, probably 
the oxycyanide solution. With both catheters in situ, draining color- 
less and green fluid, respectively, a solution of permanganate of potas- 
sium was injected into the bladder through a vesical catheter, and im- 
mediately the white fluid emerging from the right ureter was changed 
to red, whereas the green urine continued to come through the left 
catheter as before. This proved undeniably that the left catheter was 
draining the left kidney urine, but that the fluid which came from the 
right catheter, was merely the bladder fluid which was being "sucked 
up," so to speak into the ureter by the "reflux," and was passing out 
through the catheter. On operation it was later found that the right 
kidney was atrophied and was not functioning at all. — Editor.] 

Deschamps also said in his monograph;^ "The experiments of 
Lewin and Goldschmidt, of Courtade and F. Guyon, have demonstrated 



(•A'riii'yi'i';i;i/,A'ri().\ oi' tii 



n;KTKi:s 295 



tlial a red UN of 1 he hiaddci' urine low ai-<l I lie iirdci- can he pi-oducc*!, l)ul 
only ai cciiaiii iiioiiiciils; i.e., when I lie \al\ ulc opens to I'elease tlie iirc- 
loral (low. In llie normal state, lliis icllux, in oui- opinion, is a Tiog]i,i;-il)l(' 
cause of aseendin.i;' infoetion; l)ut when a iii-eler has heon oatlioterized, 
and llie valvule has been foi'ccd o]xmi, it is possi])l(' tliat tlic Tcflux takes 
place much more easily, the harrier does not seal tlie opening- hermetic- 
ally and the bladder can push its infecting- fterms toward the ureter." 
Israel," in a critical analysis of* ureteral catheterization, insists upon 
the dang-er of ascending- infection. He reports the case of a physician 
suffering' from an old ui-ethritis, Avith a sli<;-lit cystitis; Casper catheter- 
ized one of his ureters because of a jDain in tlie luml)ai- ref^ion. The 
urine thus collected by the catheter was clear and tlie patient was glad 
to know that his kidney w^as in normal condition. But on the evening 
of the same day he was suddenly seized with vomiting, fever, lumbar 
])aiiis, and chills, and he voided purulent urine. This unfortunate con- 
dition lasted a long time and the patient finally died. Tlie following is 
a complete history of the case, as connuunicated to me by Israel, Octo- 
ber 10, 1908: 

Dr. G., physician at Rostow-on-Don, Russia; had gonorrhea at the age of twenty-four 
(1893). Urine became slightly cloudy. Irrigation of the bladder unsuccessful. In 1897 
right ureteral catheterization by Casper: Right kidney urine perfectly clear, no albumin, 
normal. The following evening chills, vomiting, fever, which lasted two or three weeks. 
Urine became cloudy immediately after catheterization. During the two years following, 
there were occasional attacks of chills, vomiting, and fever, lasting one or two days; pain in 
right kidney region for several months past; cloudy polyuria. 

From that time on, the patient always suffered pain, the febrile attacks recurring at 
irregular intervals. He became gradually pale and weaker. On February 6, 1906, he came 
to my clinic, pale and weak, without appetite, tongue dry, continuous headache, and cloudy 
polyuria. Nine days later, he died in uremic coma. 

At the same time Israel sent me the histories of two additional 
cases in which renal infection resulted from ureteral catheterization. 
The following are these histories as written by the author himself: 

Case 1. — Mile. Melanie C, aged thirty-four years. Right intermittent hydronephro- 
sis; nephroptosis. Normal urine. From time to time, attacks of colic lasting two or three 
hours. After and between these attacks she felt perfectly Avell. On July 16, 1900, right 
ureteral catheterization; the instrument is arrested just above the vesical orifice of the ureter. 
July 21, ureteral catheterization is repeated with the same result; July 22, patient quit the 
liospital. She came back on August 10 to be operated upon. Since she left the hospital, 
she complains of nausea, vomiting, and frequent palpation of the heart. Urination, pre- 
viously normal, is now increased in frequency to twelve tiincs in twenty-four hours; pain 
in the bladder and urethra after micturition. Tlio riglit kidney more enlarged than in 
July, and is the seat of continuous pain; colic from time to time. Palpation of the right 
kidney is painful. 

The urine is cloudy and contains many leucocytes, a few erythrocytes and nuuiy hy- 
alin and granular easts. Evening ten\|u'rnlinr .".IM" C. Vomiting; oliguria. 

August 20, right nephrectomy. A huge cavity filled with pus; an abscess the size 



296 



CYSTOSCOPY AND UEETHKOSCOPY 



of a waluut and several small ones in the cortical substance. The mucosa of the pelvis and 
calices is red, ecchymotic, thickened. 

Case 2. — Bessie C, aged twelve years, of London. Grandfather and two *fencles. died 
of tuberculosis. For the last five years, weak, without appetite; poUakiuria, enuresis. Five 
months later Koch bacillus found in the urine. She improved slowly. Three years ago, she 
complained of slight pains in the right kidney. At present she feels well, urination every 
two and a half or three hours. No pain on urination, no pain in the kidney. Temperature 
normal; she never had fever. Urine pale, hazy; specific gravity, 1,004; albumin 0.25 per 
1,000 CO. Many leucocytes; two or three hyaliu casts; numerous Koch bacilli. 

June 27, cystoscopy under anesthesia: Mucosa inflamed, covered with fibrinopurulent 
membranes; the process is more marked on the right side than on the left; catheterization 
of the left ureter; catheter in the bladder. Urinalysis: 



FaOHT KIDNEY 



LEFT KIDNEY (BLADDER) 



Urine pale, clou( 


3y 




Urine pale, cloudy 


Specific gravity 


1,009 . 






Albumin 0.33 per 1,000 


c.c. 


1.65 per 1,000 c.c. 


Many leucocytes 






Many leucocytes 


Urea 1.4 per 1,000 c.c. 




3.6 per 1,000 c.c. 


Freezing point 


-0.60° 




-0.52° 


Few Koch bacilli 




TEMPERATURE 


Many Koch bacilli 


Date 


Morning 


Evening 


June 


28, 




38.6° C. 


i I 


29, 


38.° C. 


40.3 


e e 


30, 


37.6 


38.8 


July 


1, 


39.5 


39.2 


i i 


2, 


39.6 


39.8 


C i 


3, 


38.2 


39.1 


i c 


4, 


37.8 


37.9 


i i 


5, 


37.4 


37.5 


i I 


6, 


36.8 


37.4 


i i 


7, 


37.8 


38.8 


i i 


8, 


39.2 


39.2 


i i 


9, 


38.4 


38.2 



June 28, nausea, very frequent vomiting. 

" 29, pain in both kidneys 

" 30, urine very purulent 

July 1, tenesmus every ten minutes 

" 2, tenesmus day and night, very painful 

^' 3, vomiting 

' ' 4, much vomiting ; oliguria 

" 5, extreme nervous agitation, legs and hands cold 

" 6, vomiting of black masses 

" 7, vomiting of black masses 

^' 8, quantity of urine increased 

' ' 9, convulsions in left arm 
Coma. 

This autlior also reports a case of renal abscess wliicli lie attributes 
to ureteral catlieterization performed a few weeks previous to a 
nephrectomy done for a neoplastic kidney (DeschamiDs). 



CATMETEKI/ATIOX ol llll': I ' KI'/l'KltS 297 

I laii iiiaiiii also says:' "I liavc sccmi a ])ali('ii1 wlio incx'iitcil syiiip- 
loiiis ol' |-i,i;li( |»y('loii('|)lirilis I'oi' a loii.i;- lime, and who sliowcci syiii|i1oiii> 
of left pyelonephritis Tor the first thue a few weeks after a iircitcial 
cathetorizatioii perf'oriued l)y one of my colleagues. These iiifcrlions 
are perhaps more frequent than it is tliou^lit, Ix'cause they inaiiilest 
themselves only a certain time after the catheterization." 

At Johns Jl()])kins Hospital, Sam])son'' had a fatality icsultiii;;- from 
an ascending- ureteral infection; this was caused by a catiictci- h-fl /// 
i>itii as a guide during hysterectomy for a cancer of the uterus. 

Tlie dangers of a catheter left m situ may he seen in the i'ol lowing 
history of a characteristic case reported l^y Legueuf "This (tli<' ure- 
teral catheter a demeure) carries the risk of causing almost certain in- 
fection of the cavity. I employed it in a patient with an enormous left 
hydronephrosis; catheterization was easy, although the operation, 
which was performed later, showed a pronounced stricture ; and I evacu- 
ated nearly three and one-third liters of urine through the catheter. 

"Having repeated this evacuation several times, I wanted to intro- 
duce a catheter a demeure to permit the cavity to contract. But within 
three days, the urine became cloudy, the temperature rose, and I was 
comjoelled to abandon catheterization and perform ureteropyelotomy 
as quickly as possible. The operation Avas done transperitoneally. Tlie 
infection of the cavity spread to the opened serous membrane and the 
patient died of peritonitis in a few days. ' ' 

Tuffier* expresses the same opinion: "I was consulted by a woman 
fi'om Geneva. She had been treated for a long time in Paris, for a 
douljle pyelitis. According to her statement, ureteral catheterization 
performed for diagnostic purposes had greatly aggravated her condi- 
tion. I know of another patient, from the environs of Lille, who died 
lifteen days after a diagnostic ureteral catheterization." 

Desnos likewise had to remove a kidney infected with tubercle 
bacilli, carried by the ureteral catheter, when passed through the pros- 
tatic region in the course of a suppurative prostatitis. 

Concerning this grave danger of infection, the answer has been 
made, that ureteral catheterization should be performed oidy on a 
kidney supposed to be diseased and already infected; in the iiicaiitinu' 
the urine excreted by the opposite kidney dii-ectly through the ureter 
is collected by a catheter in the bladder. But tlie clinical lindings (we 
have ample proof in several cases) are sometimes absolutely Avrong, 
;and ureteral cathetci-ization of a healthy kidney might l>e performed 
on their data alone, thus submitting the ])atieiit to the risk of an infec- 
tion, as we have shown. In point ot fad, ureteral catheterization with 



298 CYSTOSCOPY AXD URETHROSCOPY 

the direct \T.sion cystoscope seems to be the most desiraliU/ method of 
preventing the infection of a healtliy kithiey via the ureteral^eatheter. 

EEFEEEXCES 

iRafin: Separation endovesicale . et eatheterisnie ureteral, Lron med., Feb. 12, 1905. 

-Margtdies, cited by Kejdel: Beitrage zur funktionellen Nierendiagnostik, Gentralbl. f. 
d. Eaankh. d. Harn-u. Sex.-Org., May 25, 1905, xvi, ISTo. 5, p. 225. ' 

sDeschamps: Diagnostic des affections chii-urgieales du rein. Paris. Steinlieil, 1902. 

^Israel: Was leistet der Ureterkatheterismus in der NierencMi-ui-gie f Berl. klin. Wdmschr., 
January, 1S99, No. 2. 

sHartmanu: Thesis Fontanilles, Lyons, 1901, p. 56. 

GReported by Vale: Ann. Surg., January, 1905, No. 115, p. 96. 

'Legueu: A propos des operations consei-vatrices dans les retentions renales, Tr. 13th. Inter- 
national Congiess of Medicine of Paris, 1900, Section of Urinary Surgery, August 3, 
1900, p. 15. 

sTuffier: Bull, et mem. Soc. de chir. de Paris. 1900. p. 585. 

Errors Associated With Ureteral Catheterization 

Inacciiracy is an important factor in the errors associated Avith 
ureteral catheterization. There are five principal sources of error : 

1. It is impossible to be certain tliat the caliber of the ureteral 
catheter will adapt itself tightly to that of the ureter. Consequently 
some urine might dribble down between the walls of the catheter and 
the ureteral wall, and thus get mixed with the urine of the opposite kid- 
ney which flows directly into the bladder, and thereby falsify the re- 
sults. ' '^ -^ 

This flow of a certain cpiantity of urine between the catheter and 
the ureteral wall, is indeed undeniable, and I have oV) served it fre- 
quently during lavage of the pelvis carried out for therapeutic pur- 
poses. In point of fact, the silver nitrate used for irrigation of the pel- 
vis very often drained into the bladder, where it could easily be detected 
on collecting the vesical contents with a catheter at the termination of 
the lavage. This vesical fluid usually showed an aliundant precipitate 
of characteristic silver chloride; this clearly proved that the silver 
nitrate solution which had been used for lavage of tlie kidney had 
trickled into the bladder between the catheter and the ureteral wall. 

The Ijest proof of the fact that the urine often drains (ioAvn Ijetween 
the catheter and tln^ urettual Avail, is obtained by catheterization of 
both ureters and leaving the catheters a demeure for some time. Clear 
urine may issue out of each kidney through its respective catheter: at 
the same time, a certain quantity of urine is often found in the bladder. 
which can be withdraAvn liy the introduction of a Xelaton catheter into 
the bladder. This affords certain proof of the leakage of urine betAveen 
one of the two catheters and its ureteral Avail. 



CATHETERI/ATIOX OF THE URETERS 299 

This soincc of i-iror in inctcial callioterization lias also been re- 
corded by Kouziictzky, of Pctro;;ra(l.' In ordci- to prevent this occur- 
rence, he cathoterizcs hotli ureters and then empties the bladder; after 
the examination, before removing- tlie ureteral catheters, he again 
empties the bladder of its contents. Tliis will establish the quantity of 
the urinary leakage into the bladder. In only twelve out of twenty-two 
cases was he able to prevent its occurrence. In one case, a woman, in 
spite of three distinct attempts and the use of a Xo. 8 catheter, he was 
unable to prevent tliis leakage. In two cases, the urinary leakage 
amounted to 194 and 148 c.c. respectively, for a period of two hours. 

A very characteristic case apropos of this subject was referred to 
me in the service of Rochard, at Saint Louis Hospital, on October 14, 
1907. It was the case of a young woman with a very large and adher- 
ent tumor in the right hypochondrium ; she also had pyuria. By request, 
I catheterized both ureters with the direct cj'stoscope, with the follow- 
ing result: On the left side, abundant urine, but distinctly bloody; on 
the right side, not a drop of fluid. After waiting half an hour, a cathe- 
ter was introduced into the bladder, Avhich gave forth about twenty 
c.c. of cloudy, bloody urine. Both ureteral catheters were positively 
in the ureters, because their presence Avas verified by all the assistants 
present. We were undoubtedly dealing witli a distinct leakage between 
the catheter and the ureter. 

In another case, equally clear, I obserA'ed the trickling of urine 
between catheter and ureter. A woman, Mme. L. J., aged 37 years, 
entered the service of Demoulin, at the Saint Louis Hospital, on Octo- 
ber 2, 1907. In the right hypochondrium she presented a large mass in 
which distinct fluctuation could be felt; the urine was purulent. By 
request, I examined lier under chloroform, on XoA^ember 12, with my 
direct cystoscope. Although the capacity of the bladder was only about 
40 c.c, I found the following: On the right side, an enlarged ureter, 
which emitted abundant purulent ejaculations Avith Avhite, thick creamy 
pus. I catheterized this ureter with a Xo. 7 catheter, Avhicli penetrated 
easily about 10 cm., but Avas arrested at that point. 

This catheter Avas AvithdraAvn, and the left ureteral orifice inspected. 
At first, it Avas hidden by false membranes, but it Avas soon discoA'ered. 
The bladder Avas cleaned and dried Avith small SAvabs, and a Xo. 6 
catheter easily introduced into the left ureter and left there for three 
quarters of an hour. During this time a Xelaton catheter Avas left in 
the bladder to collect the urine from the right kidney. At the end 
of the period, the separate urines from the ureteral catheter and the 
Idadder catheter amounted to practically the same quantity. Analysis 
nuide by the pharmacist of the service showed: Left kidney (through 



PLATE XIX 

Fig. 1. — Cancerous tumors of the bladder. In this case, the entire vesical 
wall was invaded by a neoi^lastic deposit, similar to that represented on 
the vesical floor. 




PLATE XIX 



CATIIKTKIIIZATIOX OF Tl I F URETERS 301 

iM-('l(M-;il callictt'i') : ri'cn, li> ,t;i';mis |)ci- lilcr, and cliloi'idcs, 4.!)() ,ui-aiiis 
per litci-. Iii,i;li1 kidiic) (1 Im()1i,i;Ii Vf'sical catliclci-) : IJroa, 1-! ,i;raiii< pci' 
liter, and chloi-idcs, i)Sh) grains per liter. 

On Novoiiilx'i- 15, Avitli tlic assistance of Dciiioiiliii, I ti('])lii-o('t()- 
mized tlie riftld kidney; I fonnd it reduced to a (lal»l)y slidl in ^vl^K•1l 
not a trace of parenchyma could l)e detected. Undoubtedly, tlie result 
furnished by the vesical catheter -while the left ureter Avas bein^? cathe- 
terized, was erroneous. The urine of the left kidney liad drained be- 
tween tlio ureter and the catheter and had trickled into the bladder. 
Both urines in spite of the difference in tlieir chemical composition, ha<l 
i-eally been derived from the left kidney alone. 

During* the operation, I was also easily enabled to determine the 
cause of the ureteral obliteration. This was due to a kink of the ureter 
in the shajie of an S, the result of a periureteritis. A catheter intro- 
duced through the renal end of the ureter was distinctly arrested and 
could not be advanced. 

Cathelin- reported an unfortunate error Avhich resulted from ure- 
teral catheterization, and which culminated in tlie death of the patient. 
A man, aged fifty-seven years, complained only of pain in the right 
kidney; he never had any pus, blood, or gravel in the urine. 

Cystoscopy and ureteral catheterization gave these results: 

right kidney left kidxey 

(catheterized) (bladder LTRIXE) 

Quantity 15 c.c. 10 c.c. 

Urea (per liter) 13.45 gm. 13.24 gm. 

Chlorides (per liter) 10.50 " 9.50 " 

Deposit Numerous broken down Xumerous blood cells, 

blood cells. few renal cells. 

"Relying," says Cathelin, "on the excellence of the urine recov- 
ered through the vesical catheter, and fearing that the patient would 
not derive any benefit from a simple exploratory operation, we decided 
upon a nephrectomy. 

"Subsequent History: The first day, 150 c.c. of urine were recov- 
ered from the bladder; the second day, 50 c.c; after that, nothing, in 
spite of the administration of lactose and theobromine. The fourth day, 
in view of this persistent anuria, we decided to do a nephrostomy of 
the left kidney. This operation showed the total absence of the kidney 
on that side. The patient died on the seventh day, and the autopsy 
confirmed the operation liiidings. There was neillier kidney nor ureter 
on the left side." 

Nicolich has reported a case in which an error was made as n re- 
sult of ureteral catheterization and confirmed by autopsy- "A woman, 



302 



CYSTOSCOPY AND URETHEOSCOPY 



complained for a long time of purulent urine, and frequent and painful 
urination. The right kidney was palpable and a little painfiJ; the left 
kidney was not palpable. Downes' instrument was used and left in 
place for half an hour; the right tul)e then gave purulent urine, while 
not a drop of urine could be obtained from the opposite side. Catheter- 
ization of the right ureter showed a retention of pus in the right kid- 
ney; the catheter was left in situ for twelve hours, Avith 
this result: Urine from the catheter, quantity, 400 c.c. 



u. w. 



cloudy, purulent; urine from the bladder, quantity, 180 
c.c, cloudy, purulent, bloody. This result might have 
been interpreted to mean that the left kidne^^ although 
Ij, „^ more diseased than the right, was actually functionating, 

^ H although as a matter of fact, it did not functionate at all, 

because it was found to be completely atrophied." 

These observations indicate what might happen 
when the caliber of the ureteral catheter is smaller than 
that of the ureter itself. When catheterization of both 
ureters is performed Avith the indirect cysto scope, only 
small catheters can be used, and if catheterization is 
continued for several hours, the urine will continually 
trickle down between the catheter and the ureteral wall, 
so that it will be impossible to estimate exactly the quan- 
tity of urine furnished by each kidney. On the other 
hand, if a larger catheter is used, and the ureter is too 
narrow to accept it, the ureter will bleed. 

The answer to this criticism Avas given at the Mad- 
rid Congress.-' Nitze at that gathering, presented new 
ureteral catheters provided with double canalization 
(Fig. 193), one for the floAV of urine, and the other for 
the injection of water into a small rubber bulb, Avhich 
when filled with water, comes into firm contact Avith the 
ureteral Avails. But this modification acts as a detriment 
to the interior caliber of the catheter, for the latter thus 
becomes too narroAV for the free passage of slightly 
thickened pus or small blood clots. 
Various methods have been suggested by other authors: 
Edgar Garceau, of Boston, devised a ucav catheter for the female, 
Avhicli can be introduced Avith the aid of my direct cystoscope. This 
catheter is 35 cm. in length, its caliber is No. 13 Charriere, from the 
external end to its center, and from this point on the diameter becomes 
smaller gradually and progressiA^ely up to the ureteral end, Avhere its 
diameter is No. 6 Charriere. 



Fig. 192.— Ure- 
teral catheter 
within a ureter. 
One can easily 
see how the urine 
trickles down be- 
tween the cathe- 
ter and the ure- 
teral wall, Ji.w. 



CATHKTKRI/ATION OF TTIE URETERS 



303 



Tlic ureteral tip of tlie eathetei- is like lliat ol' a flute; at each side 
of the instruiueut soiuewliat removed tVom the extremity, tliere are two 
eyes opposite one another to facilitate the urinary flow. Its intro- 
duction is extremely simple. First a stylet is inserted into the ureter 

through Luys' cystoscope and the catheter is 
then advanced over the stylet; inserting- it into 
the ureter is an easy matter because these ma- 
neuvers are carried out under direct control of 
the e^^'e. 

The advantages of this instrument are, 
first, the certainty that the total quantity of 
urine secreted will be collected, because the 
catheter obstructs the ureteral canal in exactly 
the same manner as a stopper corks the neck 
of a bottle. Secondly, the facility with which 
it can be introduced; this is owing to the fact 
that the ureteral extremity has a much smaller 
caliber than that of the ureter itself. 

Gudin, of Rio cle Janeiro'^ has adopted still 
another procedure, in order to obtain occlusion 
of the ureteral orifices. He accomplishes ure- 
teral catheterization with a conductor, this be- 
ing a modification of the ureteral catheter and 
stylet previously described by Albarran.*' Us- 
ing an indirect vision cystoscope, Gudin first 
introduces graduated whalebone stylets No. 4 
Charriere, and 90 cm. in length, the extremity 
of which is made of rubber, so as not to injure 
the ureteral mucosa and possibly cause a false 
passage. Each stylet is introduced into the 
ureter for a distance of about 15 cm.; then the 
indirect cystoscope is removed. The stylets 
are now left in place, and catheters with blunt 
ends are passed over them into the ureter. 
The catheter is passed over the stylet, the pre- 
caution being taken not to exert traction on the 
latter, for that miglit cause it to drop into the 
bladder ; then holding the end of tlie stylet with 
catheters whh^doubie'canais.'To ouc haud, thc Catheter is advanced over it Avith 
l^:"i:^.::Zj'Z.:^::''Z the other hand. Finally the stylet is removed. 
t.b";r'wa^te;;'';;L\r.i,:; The ureteral catheters have a caliber of 5 

ureiera'i'°waiL"''°''*'°" ""'*'' *''^ to 8 Charrlcre for a distance of a few centi- 




D- 



Ha 




304 CYSTOSCOPY AXD URETHROSCOPY 

meters ; then they dilate progressively up to No. 10 or thereabouts. 
Thej^ maintain this diameter ujd to the funnel end. .The tot£|^ catheter 
length is about 45 centimeters. In this manner it is possible to collect, 
to a certainty, the total cpiantity of urine eliminated by each kidney. 

2. A second source of error is found as a result of the passage of 
the catheter into the ureter. Without mentioning the lesion that it 
may produce in tuberculous ureteritis, for instance, a catheter may 
cause bleeding of the ureter and thus simulate a hematuria, that does 
not really exist. 

On June 8, 1904, J. AV. Keefe, replying to Kelly's paper at the meet- 
ing of the American Urological Association, reported seventy cases of 
ureteral catheterization. In forty-two cases he examined the urine be- 
fore the introduction of the catheter, in order to determine the extent 
of the damage caused by the passage of the catheter. There was no 
damage in but three of the cases. In the other cases, traces of blood 
and albumin were found ; part of the blood was due to the distention of 
the ureter. In thirteen cases h^^alin casts were foimd; nevertheless in 
only one case, were hyalin casts found before the passage of the cathe- 
ter. He considers the introduction of the catheter a dangerous pro- 
cedure, even when the catheter is perfectly aseptic. 

3. The third source of error arises from the fact that although 
catheterization is usually limited to the diseased kidne^^ the urine must 
be likewise collected from the supposedly healthy kidney via the blad- 
der. The urine of the kidney thought to be normal, comes into the 
bladder which is often infected, and it is there mixed with the jdus con- 
tained in the bladder; in such circumstances it is impossible to say 
whether the pathologic elements found in the urine are derived from 
the bladder or from the supposedly healthy kidney. 

4. The fourth source of error lies in the fact that we are not abso- 
lutely certain that the catheter is resting properly in the ureter, when 
the indirect cystoscope is employed. In fact, in order to avoid renal 
infection, some authors recommend the introduction of the catheter 
into the ureter for a distance of not more than two or three centi- 
meters. Now, if that is done, when the instrument is withdrawn so 
that the catheter alone remains, the surgeon's eye can no longer see 
Avhether the catheter is still in the ureter, or has dropped into the blad- 
der. Keydel, of Dresden, has emphasized this fact" and adds that in 
these conditions one can never be certain that an error has not been 
committed. 

5. The fifth source of error may come from the abnormal irrita- 
tion of the kidney, due to the mere presence of the catheter within the 
ureter. The secretion of this kidney may thus be changed, and incor- 



CATIIKTKTIIZATIOX ol" THE URETERS 305 

rect coiicliisioiis ;iiTi\<Ml ;il. I have on scvci'al occasions o))S('i'V('(l tliat 
upon llic iii1 rodiiclioii ol' a callictci- inio 1 ln' iii-ctci', a very distinct reflex 
polyuria was immediately i)i-o(lii<'e(|, wiiicli lasled Cor sonio timo and 
then slowly disappeared. 

This phenomenon was well illustrated and demonstrated by Frank, 
of Berlin,^ at the German Surgical Congress, in 1905, in these words: 

"I also desire to say, as Israel has already remarked, that very 
often wlien a catheter is introduced into the ureter or pelvis, the quan- 
tity of urine that flows into the bladder, may he increased or diminished, 
so that the findings are unreliahle, Wlien a catheter is inserted into 
the ureter or pelvis, the sensitive nerve centers whicli control the renal 
secretion are naturally irritated. In this manner, erroneous results 
concerning the determination of kidney function within a certain fixed 
period of time are ohtained. 

"To clear up this question, I have made a series of experiments on 
certain individuals subjected to identical dietary conditions. First, I 
catlieterized the ureters; a little later, and under the same dietary con- 
ditions, I performed separation of tlie urine (Luys' method). I found 
that when the ureters were being catlieterized, the work performed by 
the kidneys is mucli greater than when the urines were separated by 
the segregator. * * * * * This is strongly confirmed in the four cases 
which I examined particularly, taking into careful consideration the 
quantity, the specific gravity, the quantity of sugar after injection with 
phloridzin, and the variations of urea. These experiments were made in 
individuals whose kidneys did not present any pathologic conditions. 

"In one case, ureteral catheterization as opposed to the sejDarator, 
caused a spasm of the kidney; in the other case, it provoked a profuse 
polyuria. 

"In these cases, I employed Luys' separator exclusively, this being 
the only one among tlie various instruments proposed, which I con- 
sider practical." 

REFERENCES 

iKouznetzky: Riissk. Viacli., March 22, 190S, No. 12. pp. 402-404; Jour. d. riiir., .Tuuo. 

1008, i, No. ?,, p. 292. 
2Catheliii: Folia Urolooiea, March, lOOS, ii, No. 1, p. 02. 
•"'Tr. Intcrnatimial Mod. Congress, 100.3, Section on Urology, y. 71. 
4Garce:ni: P.orl. klin. Wchnschr., .June 8, 1910; 14th Mooting Assn. franc, d 'Urol.. 1910, 

p. 59G. 
■■■'Gudin: Prcsso jncd., .July Ifi, 1910, p. 546. 
f-Albarran: Tocliniciuo du catheterisme cystoscopique dos ureteros. Rev. do gynoc. al)d., 

1897, p. 474; also Intoriiational Med. Congress of Moscow, 1S97. |i. 2is. 
'Keydol: Boitriige zur funktionellen Nierondiagnostik. Contrallil. t'. d. Krankli. i1. Harn-u. 

Sex.-Org., May 25, 1905, xvi. No. 5, pp. 225-274. 
«Frank: ?.4th Congress, held in llcilin. Vrrliaiidl. d. dcuts.-ii. (iosollscli. f. Cliir., April 2(!-29, 

1905, pp. 72, 7.3, 74. 



"^06 CYSTOSCOPY AND URETHROSCOPY 

URETERAL CATHETERIZATION IN CHILDREN 

This can be effected by using indirect cystoscopes of a smaller size, 
but the visual field will be consideral)ly reduced necessarily. For this 
Treason, it is advantageous to use the direct vision cystoscope. 

Rocher and Ferron^ have emphasized this fact in an interesting- 
article : "Direct vision cystoscopy is always possible, even easy, in^ 
girls over five years of age. The urethra readily admits a No. 40 tube, 
7 cm. in length, and although the visual field is reduced, the short 
length of the tube makes exploration of the bladder possible. In a tol- 
erant bladder, a slight Trendelenburg position is sufficient to produce 
vesical distention. At this early age, this modified position is readily 
accepted. 

''In young girls, the bladder does not differ from that of the mature 
woman. Although the interureteral ligament may not be so marked, 
we have, nevertheless, seen it quite distinctly. 

"The ureteral orifice usually admits a No. 6 or 7 catheter. In one 
of our patients, neither orifice admitted anything but a very fine bougie. 
We believe that this condition has no connection with the age of the 
patient, since we meet it in the adult, as well, and every specialist has 
noticed it in some of his cases. 

"We have frequently employed general anesthesia, not because 
these maneuvers are painful, but because children are often frightened 
on seeing our instruments, and thus become unmanageable. ' ' 

REFERENCE 

lEocher and Ferron: Tuberculose renale chez 1 'enfant, Jour, d 'Urol., 1913, i, p. 153. 



CHAPTER VIII 

INFORMATION DF.RIVED THROUGH URETERAL 
CATHETERIZATION 

INDICATIONS FOR URETERAL CATHETERIZATION 

Catlieterization of tlie ureters should be reserved exclusively foi- 
ox])loralion of the iireter and the renal pelvis. For a complete consid- 
eration of ureteral catheterization and the functional tests of the kid- 
neys, the reader is referred to a separate work on this subject by the 
author/ In the present chapter, we shall therefore consider only the 
data furnished by catheterization of the ureter and pelvis. 

Exploration of the Ureter 

Ureteral exploration will reveal two principal pathologic condi- 
tions of this canal; i.e., stricture or obliteration, and calculi. 

A. Stricture or Obliteration. — The difference between a stricture 
and an obliteration of the ureter, is not of great importance in the pres- 
ent connection. The fine ureteral catheter which is arrested at a cer- 
tain spot, indicates in the simplest possible manner the exact location 
of the stricture, kink, or obliteration. 

Ureteral strictures are recognized by the fact that a fine catheter 
will advance beyond a certain point at which a larger catheter is ar- 
rested. Ureteral obliterations, on the other hand, arrest all catheters 
at a given point,. however fine they may be. The location of this jDoint 
can be determined by measuring the exact length of catheter that has 
been introduced into the ureter. 

B. Detection of Ureteral Calculi. — Searching for a calculus with 
the aid of the ureteral catheter results in very valuable information. 
When the catheter passes alongside of a calculus embedded in the ure- 
teral wall, a distinctly characteristic grating sensation can be felt. 

I have personally observed a case^ in a man, aged thirty-nine years, 
who consulted me on November 29, 1907, l)ecause of numerous attacks 
of renal colic; sometimes the attacks were on the right side, at other 
times on the left, and they extended over a period of nine years. I 
catheterized the left ureter with a No. 7 catheter, through my direct 

307 



308 



CYSTOSCOPY AND URETHEOSCOPY 



vision cystoseo23e. The catheter advanced to the renal pelvis, but Avhile 
I was withdrawing it slowly, I distinctly felt a sensation of«»gTating. 
PajDiDa, an intern of the HosiDital, who was iDresent, observed the same 
sensation. The diagnosis of a calcidus seemed to be well founded. 

Though radiography was negative, the patient passed two stones, 
each twice the size of a bean, nine days later. To make sure that 
these stones were identical with those felt ■with my catheter, I catlie- 
terized him again on December 13, 1mt did not observe any sensation 
of friction. 

Kelly, of Baltimore,' published reports of 38 cases, and has re- 
jDcatedly emphasized the importance of this method in searching for 
ureteral calculi. For this jourpose Kelly covers his catheter tip with a 
coating of oil and wax, j^repared as follows: Olive oil, 100 parts, dental 
wax, 200 parts. 

The tip of the catheter is plunged into tliis solution wliile it is still 




Fig. 194. — Wax-tipped catheters bearing the scratch marks of a calculus (Kelly). 

slightly warm, and then permitted to cool in the air. The catheter thus 
acquires a polished, smooth and very delicate surface. The greatest 
care must be taken to deposit this coating miiformly over the catheter, 
so that there will l)e no appreciable roughness or unevenness on its sur- 
face. 

This procedure will not only show the presence of a stone, but also 
its size as well. The deepest scratch marks are made by stones embed- 
ded in the ureteral wall, and wliich can be neither moved nor extracted. 

Considerable difficulty is encountered in determining the exact 
location of the calculus. To obtain this information, Kelly resorts to 
the method described by SamiDSon, namely, of depositing at intervals 
on the length of the catheter, a series of small olivary masses of wax. 
T\lien all these wax olives present an uninterrupted scratch line, we 



INDICATIONS KOi; rKKTEHAL CATTIETEUI/ATIOX 



300 



"lay l)(' ccrlaiii we aiv dcaliti- \\i1li a urcUTal sloiio. On Die other 
liaiid, llic (listaiicc Ix'twccMi tlic stoiK- and tho pelvis can I)c dctcrniiiicd 
l>y incasiinii- th,. Icii-lh ol' Ww scraldi iiiai-k; and in Hm' same niaiiiior 



M^^J 




Fig. 195. — Ureteral calculi 



llie distance from tlie calculus to the ureteral orilice can also be easily 
determined. 

Kelly indicates the ^Jossible sources of error with this procedure: 



PLATE XX 

Fig. 1. — Inflammatwn of the Madder neck. On the floor are seen enormous 
edematous and hemorrhagic masses, which could be revealed only by the 
direct vision cystoscope. It is readily seen how these edematous masses, 
as the result of their evolution, can tend to the development of small 
papillomata, such as are illustrated in Plate XVII. 

Fig. 2. — Localized abscess of the bladder necTc. In this case, continuous 
recurrences of an obstinate urethritis were cured only as a result of 
incision of the abscess with the galvanocautery. 




Fig. 1. 




Fig. 2. 

PLATE XX 



INDICATIONS FOR URETERAL CATHETERIZATION 311 

1. Friction of the waxed tij) with the cystoscopic tube. In this 
case, a flat and uniform depression is obtained, instead of a scratch line 
which a stone produces. 

2. When the catheter is withdrawn, care must be taken not to per- 
mit it to come in contact with the pubic hair, which might impress a 
deceptive scratch mark on the wax. 

3. The catheter should be inspected thoroughly before it is intro- 
duced, to be assured that it is perfectly smooth throughout. 

In spite of these possible shortcomings, this procedure seems to be 
an excellent one. In renal calculi, however, it may fail ; exact informa- 
tion can not be obtained when the renal pelvis is considerably dilated, 
or when the stone is small; and when the calculus is lodged in cavities 
in the substance of the renal parenchyma, the waxed tip is of no prac- 
tical value whatever. 

Another method which seems to avoid these disadvantages, was 
recommended by Follen Cabot.* This author attached the free end of 
the ureteral catheter to a stethoscope, or better still, a phonendoscope. 
He also placed a smooth metallic stylet in the interior of the catheter, 
one end protruding slightly through the eye of the catheter. The slight- 
est contact between a stone and the tip of the metallic stylet, will be 
distinctly heard by the observer with the phonendoscope. According 
to this author, not only can the presence of a stone be detected with this 
method, but also its exact location in the ureter or the pelvis. 

The ureteral catheter detects the presence of calculus in the ureter; 
but when the stone is situated in the lower part of the ureter, it can also 
be extracted with the aid of my cystoscope. The following case illus- 
trates this point nicely: 

A woman, aged thirty-one years, in the service of Pozzi,5 had a calculus in the right 
ureter; its presence was confirmed by a radiogram made by Infroit, and also by vaginal 
examination. Ureteral catheterization with the direct cystoscope showed that all catheters 
were arrested at two centimeters from the ureteral orifice. A series of progressive ureteral 
dilatation was instituted, using flexible metallic bougies, Nos. 8, 10, 12, and even No. 16 
Charriere. In this manner, I succeeded in obtaining a very distinct calcular contact. 

To increase the dilatation, I then introduced bougies which were left in situ in the 
lower end of the ureter, for twenty-four hours. I then decided to attempt the extraction 
of the stone with a foreign body forceps; this entered the ureter easily enough, but I did 
not succeed in grasping the stone, nor could I move it from its position. 

The diagnosis of embedded calculus was made, and verified a few days later, on opera- 
tion by Pozzi. He did a subperitoneal lateral laparotomy and extracted the stone, with 
considerable difficulty. It was found completely embedded and very adherent to the mucosa, 
. a fragment of which came away with the stone. In this particular case, it can be easily 
seen why the intraureteral intervention was unsuccessful. 

Other foreign bodies, besides calculi, can lilvemse be extracted 
with fine forceps. This is well illustrated in the case fully described 



312 CYSTOSCOPY AXD UEETHROSCOPY 

on page 375. [Repetition of the details of this case lias been thought 
inadvisable by the editor, who has taken the liberty of merely«j'efeiTing 
to it. — Editopv.] 

Another useful indication for ureteral catheterization, is to intro- 
duce a catheter into the ureter, to act as a guide in operations upon 
the ureter or ujDon adjacent organs. . 

KEFEPtENCES 

iLuys: Exploration de I'appareil urinaiie, Paris, Ma&sou, 1909, eel. 2, p. 519. 

2Luys: Bull, et mem. Soc. de cliir. de Paris, Feb. 12, 1908, p. 211. 

3Kelly: My Experience with the Keual Catheter as a Means of Detecting Renal and Ureteral 

Calculi. Read before the third annual meeting of the American Urological Assn., 

June 8, 1904. 
4Follen Cabot: A New Method for Detecting Calculi in the Ureter and Kidney, Am. Jour. 

Urol., March, 1905. 
sPozzi: Bull, et mem. Soc. de chir. de Paris, Feb. 26, 1908, p. 286. 

Treatment of Nephritic Colic 

This most useful application of ureteral catheterization in ne- 
phritic colic, has already been mentioned above. It is based on the gen- 
erally accepted theory that nephritic colic is the result of a stone which 
starts from the renal pelvis and becomes engaged in the ureter on its 
way to the bladder. 

Formerly the usual treatment was purely medical. It consisted in 
placing the patient in bed and the administration of hypodermic injec- 
tions of morphine. This treatment was unquestionably uncertain and 
did not give the most effective results. At present, ureteral catheteriza- 
tion, properly employed, seems to be the most desirable method of 
treatment. We may properly ask, "Why should we leave this task to 
be done poorly by nature, when we can aid her materially in her effort?" 

The calculus has a tendency to descend along the ureter; then why 
not encourage this tendency and facilitate this movement, particularly 
when the stone has been retained for some time or even may remain 
indefinitely in the ureteral canal because of some roughness of its sur- 
face? It is also essential to avoid at any cost the grave complications 
like hydronephrosis and consecutive renal infections which often result 
from the retention of a stone, and which are invariably fatal in their 
consequences. 

The following history of a case is particularly typical : 

A man, aged sixty years, who had been in the habit of taking his annual cure at 
Contrexeville, found himself unable to take his usual treatment. On June 17, 1911, while 
feeling perfectly well, he suddenly felt a sharp pain in the right kindey, which radiated 
down the ureter toward the testicle, and had all the characteristics of renal colic. Tliis 
condition lasted two or three days without cessation. 



DETERMIXATinX OF rFJ.VIC CAPACITY 616 

On June 10, BoIult, wlm was attcMidiii^ him, oliservcd tliat bimanual palpation of the 
right kidney produced a constant and very characteristic pain; also that rectal examination 
provoked a sharp pain when the inferior extremity of the rij^ht ureter was palpated. Tlie 
patient was then referred to me for a cystoscopic examination. 

I found the bladder perfectly normal; likewise the left ureteral orifice. But the right 
ureteral orifice was dilated enormously; the vesical portion of the ureter seemed turgid, in- 
flamed, and dilated so that it resembled the neck of the uterus. This was highly suggestive 
of a ureteral lesion. A Xo. G catheter penetrated about one centimeter into the ureter, where 
it was arrested for a few moments, during which time it was noticed that pus was exuding 
from the ureteral orifice. After a few attempts, the catheter was advanced further and 
we found that there was an undoubted pyelitic retention of about 33 c.c. The fluid thus 
obtained was bloody and contained blood clots. The pelvis was irrigated with a 1:1000 
solution of silver nitrate ; and while the catheter was being withdrawn, a very typical and 
characteristic friction sensation was distinctly felt. 

The patient went home, relieved of all his pains. The same evening he voided a small 
stone with the urine; the latter became clear and all morbid symptoms disappeared. 

In this case, therefore, catheterization produced, an excellent result; on the one hand, 
it relieved the patient of his pains, and on the other, it prevented the usual complications; 
i. e., hydronephrosis, pyonephrosis, renal infection, etc. 

Exploration of the Renal Pelvis 

The indications for the exploration of the pelvis with the ureteral 
catheter, may be summed up as follows: 

1. The Detectiox" of a Calculus ix the Pelvis. — The operative 
technic is the same as that for ureteral calculi; full details have been 
given in the preceding chapter. 

2. To CoxFiKM A DiAGxosis. — 111 difficult cases when the diagnosis 
is doubtful, it is not known whether the disease is located in the kid- 
ney, or in surrounding organs; i.e., the sijleen, liver, ovary, etc. In such 
instances, following Kelly's suggestion,^ it is Avell to catheterize the 
ureter and distend the pelvis with a fluid injected slowly. A slight pain 
is thus produced, and when the patient recognizes this pain as being- 
similar to his usual pains, their renal origin may be taken for granted. 

3. To Deteemixe the Capacity of the Eex^al Pelvis. — This is an 
extremely interesting subject, which has not yet been thoroughly devel- 
oped. 

Determination of the Pelvic Capacity 

The systematic study of the pelvic capacity enables us to estimate 
the degree of destruction of the renal parenchyma and also furnishes 
definite and valuable indications as to the surgical measures to be taken. 
In cases in which there is a considerable pelvic dilatation, there must 
be urinary stagnation or suppuration, the amount of which must be de- 
termined. If this suppurating focus is considerable in quantity, noth- 
ing but nephrectomy can be advised. On the other hand, Avhen the 



314 CYSTOSCOPY AND URETHKOSCOPY 

pelvis is but slightly dilated, stagnation is limited and the complete 
removal of the kidney is therefore not indicated. ^ 

Exceptions must be made, however, in renal tuberculosis and neo- 
plasms. In these conditions, when the diagnosis of tuberculosis or neo- 
plasm has been definitely made, nephrectomy is the operation of choice 
with the vast majority of surgeons. But in other conditions, renal 
lithiasis or hydronephrosis, for example, the capacity of the pelvis is 
a preponderating factor in the method of treatment to be adopted. 

It is absolutely essential to possess precise information before the 
surgeon takes his knife in any surgical intervention on the kidney. 
Some surgeons are satisfied with clinical symptoms, or with the find- 
ings of the kidney exposed on operation; but these are really not wise 
procedures, for it has often occurred that even with the kidney deliv- 
ered, the surgeon has been unable to determine Avhat was wrong with it. 
It is therefore far more rational, more definite and more prudent, to 
examine the patient methodically so as not to operate blindly, but ac- 
cording to exact information acquired beforehand. 

Techi^ic of the Determinattox or the Pelvic Capacity 

The catheter is introduced into the ureter and up to the pelvis, and 
left there for a few moments, during which time the urine flows normal- 
ly. Then the patient is placed in the horizontal position. A graduated 
syringe, filled with boric acid solution, is attached to the catheter and 
the fluid injected very slowly and carefully, meanwhile instructing the 
patient to announce when he feels the slightest sensation of pain. In 
the normal case, this pain appears suddenly as soon as about five c.c. 
have been injected. If the injection is not made very slowly, extremely 
violent pains may result. 

The advantages of this procedure may be realized from the follow- 
ing case histories: 

Case 1. — M. S., male, aged fifty-six years, was referred to me, on July 1, 1905, by 
Suarez de Mendoza, of Madrid. Thirty years previously he had had several attacks of right 
renal colic, which culminated in the expulsion of small calculi. 

He was perfectly well up to two and a half years ago, when he was suddenly seized 
with severe pains on the left side, followed by hematuria of renal character. At times the 
urine was clear, at other times bloody. Six months ago, the hematuria ceased and the urine 
became purulent. 

On examination the urine was found purulent. Guinea-pig inoculation done some 
time previously, v/as negative ; the animals gained in weight and were in excellent health 
since the inoculation. 

The urethra is free, the bladder has an excellent capacity, and the kidneys can not 
be palpated. 

Urinary separation was easily accomplished, with this result : On the right side, the 
urine is normal and flows in rhythmic and regular ejaculations; on the left side, the urine 
is foul and cloudy, and flows continuously drop by drop. 



DETERMINATIO]^ OF PELVIC CAPACITY 



315 



Chemical analysis shows the following: 









RIGHT KIDNEY 


LEFT KIDNEY 


MIXED (BLADI 


Quantity 






8.7 c.c. 


8.6 c.c. 




Freezing 


point 




-1.48° 


-0.72° 


-0.20° 


Urea per 


1000 


c.c. 


14.12 gm. 


6.55 gm. 


12.88 gm, 


NaCl 






8.50 " 


5.00 " 


8.50 " 


Index oi 


: refi 


rac- 








tion 






1.340,822 


1.336,670 


1.338,960 








Microscopic Elements 


Principally pus and 


Solely pus 


Sediment 






1. Numerous red 
blood cells; 

2. Polynuclear leu- 
cocytes, much in ex- 
cess of the white 
blood cells, but con- 
siderably less in quan- 
tity than on the op- 
posite side; 

3. Bladder cells. 


a few bladder cells. 





The diagnosis was clear: Left pyonephrosis with sufficient function of the right 
kidney. The necessity of surgical intervention on the left kidney was imperative ; but 
what was the particular operation that was indicated? 

To answer this question, I catheterized the left ureter on July 8. The pelvic capacity 
in three different tests, was fifteen c.c. each time. This showed that the pelvis was but 
little dilated and that the renal parenchyma was but slightly damaged. Consequently 
nephrectomy was rejected, and nephrotomy decided upon. 

The patient was referred to Beclere, for a radiogram, which revealed the presence of 
calculi in the left kidney. 

These three successive examinations therefore gave us the following data: The seg- 
regator showed a left pyonephrosis ; catheterization showed little pelvic dilatation and slight 
parenchymatous destruction; and the radiogram demonstrated the presence of calculi in the 
kidney. 

Nephrectomy was performed by de Mendoza, at Madrid, on September 10. He found 
five stones in the pelvis and upper portion of the ureter. 

By way of contrast with the preceding case, the following case 
may be mentioned: 

Case 2.— H. M., female, aged forty years, had been pregnant fourteen times ; ten 
went to full term and the others were abortions. Most of her children died in early infancy. 
The patient now has but two living children, one nine and a half years old, healthy, the 
other seven, with Pott's disease. Patient had measles and chicken pox in her youth; other- 
wise she was always well up to her twelfth pregnancy, when she had attacks of hematuria 
and aborted in the fifth month. After the abortion the hematuria ceased. But the urine 
has always been cloudy since then, leaving a whitish precipitate on standing. 

During her last pregnancy, when she was two and a half months pregnant, she en- 
tered the maternity ward of the Saint Antoine Hospital, in the service of Bar (December 
11, 1903). At that time, the urine was purulent, with an abundant white deposit. Micro- 
scopic examination revealed numerous pus cells, but no blood cells. Bimanual palpation 
of the left kidney revealed that it Avas painful on pressure and enlarged. No pain over the 
right kidney, nor in the hypogastric region. 

Separation of the urines was perfornied by me on December 19, and showed clear 



316 



CYSTOSCOPY AND UKETHROSCOPY 



urine on the right side, and purulent urine on the left. Chemical analysis of the separated 
urines, made by the intern of the pharmacal service, was as follows: 



Reaction 

Urea (per liter) 

Chlorides 



RIGHT KIDNEY 

acid 

29.84 gm. 
9.00 " 



LEFT KIDNEY 

alkaline 
2.56 gm. 
4.00 '' 



MIXED (bladder) 

acid 
12.66 gm. 
8.00 " 



This examination showed that almost all the urinary depuration was being done by 
the right kidney. 




Fig. 196. — Calculous pyonephrosis (external aspect). 

At that time, the patient was two and a half months pregnant. This was terminated 
in the sixth month by an abortion. She came to see me on April 28, 1905, presenting a large 
painful mass on the left side; it moved distinctly with the respiratory movements. 

The left ureter was catheterized with my direct cystoscope. Nothing came through 
the ureter at first, but after bimanual pressure, a flow of pus appeared. The pelvic capacity 
was over 150 c.c. On May 4, a second catheterization gave the same results, and the patient 
felt pain only when 150 c.c. had been injected. 



l)ETERMINy\TlON OV PELV[C CAPACITY 



3r 



T'lic ovidoiK'o ill tliis cMse \v;is clear. Wo were deuliiiw- witli an eiionrious left pyo- 
neplirosis; tlie renal paienehyma was iiiueli altered, it not totally destroyed; nephrectomy 
was clearly indicated. 

This was done on May 23, at Laennee Hospital. The kidney was enoinions (Figs. 




Fig. 197 —Calculous pyonephrosis. The calculus !s seen in the center of the pelvis, and is illus- 
trated separately m the lower left hand corner of the illustration. The pelvic capacity of this kidney 
was over ISO c.c. ^ j 

196 and 197). It was irregular in shape, its walls were thinned, the parenchyma converted 
into a purulent sac; at the hilum, in the pelvis, we found a large calculus. 

A third instance seems even more characteristic : 

Case 3. — A woman, aged iifty-threc years, was referred to me on November 15, 1905, by 
Gaston Alexandre. She complained of having had cloudy urine for over a year; occasionally 
she had henuituria aggravated by walking or riding, and disnppearing under the intiuence 



318 



CYSTOSCOPY AND URETHROSCOPY 



of rest. She also had a slight increase in urinary frequency, — every two hours by day, and 
three times during the night. 

On examination, the urine is cloudy, with a heavy deposit; the bladder seems to be 
normal ; its capacity is over 250 c.c. ; irrigation is easy, the fluid coming out clear rather 
quickly. Palpation of the kidneys .is negative; neither organ can be felt; there is no 
ureterovesical reflex. 

Separation of the urines showed that the urine from the right kidney flowed with 
regular and rhythmic ejaculations, and was perfectly clear; from the left kidney, the 
urine was very cloudy. Chemical analysis made by Maute, showed the following: 







EIGHT KIDNEY 


LEFT KIDNEY 


MIXED (bladder) 


Quantity 




11.8 C.C. 


10.2 c.c. 




Urea per 


liter 


10.93 gm. 


11.92 gm. 


10.92 gm. 


Freezing point 


-1.36° 


-1.40° 


-1.42° 


Index of 


refrac- 








tion 




1.338,770 


1.338,998 


1.339,606 


Sediment 




1. Some red blood 


1. In great quan- 


1. Polynuclear leu- 






cells, with occasional 


tity; polynuclear leu- 


cocytes abundant (py- 






leucocytes (in the pro- 


cocytes, constituting a 


uria). 






portion of blood ele- 


dist i n c t microscopic 








ments). 


pjTiria. 








2. Occasional blad- 


2. In small num- 


2. Some bladder 






der epithelium. 


bers in the same pro- 


cells. 






3. Crystals of oxy- 


portions as on the op- 








late of lime. 


posite side, — red 
blood cells and blad- 
der cells. 





The diagnosis of left pyonephrosis was made. To determine the condition of the 
left kidney, the left ureter was catheterized on- November 21, with my direct cystoscope. At 
that time the patient was in the midst of an attack of hematuria. The bladder seemed nor- 
mal, likewise both ureteral orifices. A No. 7 catheter was introduced up to the kidney and 
a distinctly bloody urine was obtained. At the same time, a soft catheter (Nelaton) placed 
in the bladder, showed that the urine coming from the opposite kidney was clear. A second 
chemical analysis was made by Maute with the following result: 



Quantity 
Freezing point 
Urea (per liter) 



EIGHT KIDNEY 

11 c.c. 

-1.62° 

12.73 gm. 



LEFT KIDNEY 
7 C.C. 

-1.62° 
13.50 gm. 



Sediment 



Abundant amorphous 
urates. 

Uric acid crystals. 

Fairly numerous red 
blood cells, about ten 
times as many as on the 
opposite side. 

Also bladder cells. 



Very many red blood 
cells. 

Very many polynuclear 
leucocytes, constituting a 
real pyuria. 

Some small round epi- 
thelial cells from the kid- 
ney or pelvis. 

Large epithelial cells 
in round heaps, with a 
large nucleus, and which 
it is diflicult to localize. 

Numerous cocci ar- 
ranged in pairs and in 
masses. 



DETERMINATION OK PELVIC CAPACITY 319 

Tlic Ifl'l pchii- ciiiiai'il y \\;is ('(juihI di lie liaii'ly two i-.c. ; 1liis sliuwcil lliat it was 
nut (listcjiilcil. A ia(li()<;r:im was made liy Jiecli-'ic, wlm slalcil Ilia1 ''tlio oxamiiial inn .if 
this iiictuii' (Idcs iiiit ^ivf doriiiilc ov'ulciu'o of tlic jiicsciicc (Ji- alisriiiT nf a stone." 

Conseqiiciitly we tliou^lit we liiul a case of sini|j|c pyelitis. Tlie jielvis was iiri<^ate<l 
once in eis'l't days for a iiioiitli. Tliesi' iiii<;ations, made witli a 1:1000 solution f)f silver 
nitrate, immediately stopped the hematuria for about four days, after which period it re- 
appeared. Tlic icsult lu'iiij; uiisat isfadory, an opeiatioii was decided iijion after eoiisulta- 
tion with AU'.xandre. 

Ill ])()iiit of fact, sejjaration of the urines poinlcd lo a left iiyoiicpiirosis ; the |jci\ii- 
capacity demonstrated there was no dilatation. Finally, the Iwo (dicniicjil analyses indi- 
cated a normal functional capacity for the left kidney. 

We comduded that the kidney should be conserved, and decided upon a neplirtjtomy. 
This was done by Alexandre and myself on January 27, 1906. A large lumbar incision was 
made, the kidney exposed, and through the external surface of the organ, I could distinctly 
feel the presence of a stone. The outer margin of the kidney was incised and the parenchyma 
split open up to the pelvis. The index finger introduced into the pelvis, easily delivered an 
extremely large, movable calculus. It seems very hard, is 12 mm. in length and 11 mm. in 
breadth. The ureter seems normal. The wound was closed with two rows of catgut sutures ; 
finally, three planes of sutures for the muscular and superficial layers. Recovery without 
incident. Alexandre saw the patient again two years later; she w'as in excellent condition. 

It can therefore be seen, from a study of these three cases, that the 
capacity of the pelvis should be known definitely before resorting to 
operation. The principal advantages of this procedure, are these: 

1. In renal lithiasis, hydronephrosis, simple nontuberculous pyo- 
nephrosis, the exact knowledge of the pelvic capacity will determine 
whether nephrotomy or nephrectomy should be performed. We do not 
pretend to say that this method of diagnosis is the only one to decide 
this question, but it will undoubtedly contribute materially in the selec- 
tion of the operative procedure. 

2. "When the pelvic capacity is found greatly increased, and 
nephrectomy has been decided upon, it is highly important that this 
operation should be performed at once, without preliminary incision 
into the organ, so that if pyonephrosis is revealed, the kidney can be 
removed in its entirety. By doing this, it will be possible to avoid in- 
fection of the wound by the renal pus, and will permit closure of the 
wound by primary union; this occurred in our Case No. 2, just de- 
scribed. 

REFERENCE 

iKelly: The Use of the Renal Catheter in Determining the Seat of Obscure Pain in the 
Side, Am. Jour. Obst., 1899, xl. No. ?,. 

Ureteral Catheterization in Kidney Function Tests 

In the performance of functional tests of the kidney, the role of 
ureteral catheterization is extremely limited, — much more so than in 



320 CYSTOSCOPY AXD rRETHEOSCOPY 

the exploration of the ureters and pelvis; and it should ])e employed 
only in such cases in which my "urine segregator" can notjDe utilized. 

It goes without saying that the duality of the renal glands necessi- 
tates a double analysis; the analysis of the separated urines is there- 
fore universally accepted as a matter of routine, We shall not empha- 
size this point; it is sufficient to say tliat this important idea is due to 
the unceasing efforts of Albarran, who advocated it steadily since 1897. 

Beyond doubt, the simultaneous ureteral catheterization continued 
during twenty-four hours is the only method that is stricth^ and abso- 
lutely exact. This is indeed an ideal theoretical method, but in actual 
j)ractice it can not always be carried out. 

Xor shall we enter into the discussion Avhicli raised such violent 
polemics between the advocates of my "separator" and those who 
favored ureteral catheterization. This Cjuestion, which will be the 
subject of another work, does not seem to be within the scope of this 
book, devoted solely to the study and consideration of vesical 
endoscopy.^ 

EEFEEEXCE 

iLuys : Exploration de 1 'appareil urmaire, Crowned bv tlie Academy of Medicine, Laborie 
Prize, 1907, Paris, Masson, 1909, p. 430; also, Presse med., Aug-ust 24, 1910, p. 641. 

Treatment of Pyelitis by Pelvic Lavage 

Lavage of the pelvis, studied for the first time in France by 
Albarran in 1898, can not be applied in every case of pyonephrosis. 
In renal tuberculosis, it has no value whatever, and moreover, it is 
absolutely contraindicated. Its best results are attained in the milder 
types of pyelitis, without extensive involvement of the parenchyma. 
In renal lithiasis, iDelvic lavage has no more effect than bladder irri- 
gation has on the cystitis which accompanies a vesical calculus. To 
rejDeat, then, pelvic lavage is of service only in the mild forms of 
pyelitis. 

In an interesting memoir published in 1904:, Eafin, of Lyons, has 
well said that pelvic lavage is efficacious only in cases in which there 
are no mechanical obstacles, because in such cases surgical interven- 
tion is absolutely essential. Lavage may be utilized as palliative treat- 
ment when there exists a contraindication to operation, or for the alle- 
viation of local or general symptoms before surgical intervention. 
"When pelvic irrigation is followed by untoward phen(^mena, like chills, 
or a rise in temj)erature, it must be discarded. 



PELVIC LAVAfJE 321 

Techxic of Pelvic Lavage 

For lavage, the largest possible ureteral catheter must he em- 
ployed, — No. 7 or 8; the tip should be flute-shaped, and should bear 
two lateral eyes. The catheter is introduced into the ureter and ad- 
vanced until slight resistance is felt. At this moment the progress 
of the catheter must be stopped so as to prevent its coiling upon itself 
within the pelvis. The ideal position of the catheter is with its ex- 
tremity at the entrance of the pelvis, just as a vesical catheter should 
be at the vesical neck, in irrigation of the bladder. The best way to 
determine whether or not the catheter is properly placed, is to wait 
a few^ moments and observe whether the flow of urine from the pelvis 
is normal or otherwise. If the catheter is advanced too far, it can 
easily be withdrawn a few centimeters toward the low^er extremity of 
the pelvis ; but it is quite difficult to push it forward again. In practice, 
the catheter is therefore advanced with the cystoscopic tube until it 
begins to bend on itself at the external ureteral orifice. 

The cystoscope is no^v withdrawn; the patient is placed in the 
full horizontal position. When the urinary flow is not normal it is 
advisable to withdraw the catheter one or two or even three centi- 
meters, at the most. In an infected pelvis, irrigation should not be 
begun until the purulent urine has ceased flowing under manual pres- 
sure; that is, when the drops fall from the catheter slowly, at long 
intervals and without force. 

Effective lavage is attained only after the pelvic mucosa has been 
cleansed of all its pus; that is, when the boric acid solution comes out 
perfectly clear. To obtain this result, the solution is injected with a 
syringe, provided with a fine cannula, that can be fitted tightly to the 
catheter. The injection is continued until a slight pain is felt by the 
patient in the corresponding hypogastrium. The piston of the syringe 
is pushed very slowly and gently so as to avoid the creation of any 
tension in the pelvis; this might bring on severe pain and possibly 
syncope. 

The quantity of fluid thus injected, varies according to the indi- 
vidual patient; sometimes 10 c.c. are sufficient, while at other times 
even 150 c.c. are insufficient to fill the pelvis to its maximum cajDacity. 

Evacuation of the filled-up pelvis can be accelerated by slightly 
pressing the abdominal wall in the region of the affected kidney; or 
the patient himself may assist by contracting his diaphragmatic and 
abdominal muscles, as in coughing. In a particular case, I once ob- 



PLATE XXT 

Fig. 1. — Bullous edema of the vesical fundus. The result of a concomitant 
uterine cancer, ''Cushion" appearance. 

Fig. 2. — Initial pliase of the invasion of the vesical fundus by cancerous 
infiltration due to a concomitant uterine cancer. The mucosa has a 
dark, ecehj-motic color, and in various places jDresents slight hemor- 
rhages. 




Fig. 1. 




Fig. 2. 

PLATE XXI 



iiK'i'i:i;.Mi.\.\'ri().\ oi- i'i:r.\ic cai'acitv 323 

served lliat tlic in-i.unliiii;- lliiid (lowrd (nil of the catlie'ler in a contin- 
uous .stream as a residt of llic ciTorts made by the patient. 

After the cleansing irrigation lias Itccii coinplcicd, tlic Ilici-ai)entie 
lavage is given, the following solutions being connnonly used: 

SoLUTio^^s E.^rPLOYED. — A 1:1000 solution of silver nitrate has 
always given me the most satisfactoiy results. Dilute hydrogen perox- 
ide invariably gave me the poorest results. It decomposes, producing 
numerous gas bubbles, which are too large to pass out of the ureteral 
catheter; they thus inflate the renal pelvis and ])roduce considerable 
pain. This solution should never be employed. Potassium permanga- 
nate irrigations, 1 :4000, also give good results. Oxycyanide of mer- 
curj' , 1 :8000, have been used b}^ Feodorff. Collargol, 2 or 3 per cent, 
can be used, but Legueu has observed infiltrations and infarcts of the 
renal parenchyma after its emi)loyment. Aluminum acetate, 1 per 
cent, has been used by Kail. [American authors seem to prefer Argy- 
rol, for pelvic lavage, in solutions varying from 5 to 25 per cent. — 
Editor.] 

Frequency and Number of Irrigations. — These vary according to 
the individual case. They depend on the nature of the infection, the 
degree of pelvic distention and a number of other concomitant s^inp- 
toms. On the average, lavage should be performed about two or three 
times weekly, depending on the case. In the great majority of cases, 
once a week is usually sufficient. 

In some cases of pyelitis, excellent therapeutic results can be ob- 
tained in a short time, after two or three irrigations. I have seen a 
very interesting case, with Abel Desjardins, the patient being a woman 
with febrile movements, purulent urine, and painful right kidney. The 
patient was completely cured after three irrigations. 

In other cases, pelvic lavage must be repeated more often and 
carried out with considerable patience. Kelly catheterized a patient 
120 times before he obtained the desired result. 

Notwithstanding the fact that the pelvis may have been thoroughly 
and permanently disinfected through lavage, patients should be kept 
under careful observation, because of the possibility of recurrence. 

When this method of treatment is unsuccessful, it is usually due 
to an existing infection of the renal j^arenchyma. 

The following is the history of a case of pyelonephritis treated 
with pelvic irrigations: 

Ivight Pyelonephritis Treated With Pelvic Lavaqc. — L. CIi.. male, aged tliiity-five 
years, presented himself on July 17, lOO.", complaiiiino- of cloudy urine of tliree vcars' dura- 



324 CYSTOSCOPY AND URETHROSCOPY 

tioii. Some time previously he had jjassed urine containing red sand, but since then his 
urine became cloudy and the sand had not reappeared. His general condition is good, no 
pain on urination, no increased frequency, but has a constant pain in the isight kidney 
region. The ureter is normal, bladder likewise, with a capacity of over 450 c.c. His urine 
is very cloudy and contains pus. The left kidney can not be palpated ; the lower pole of 
the right kidney is slightly perceptible. 

Urinary separation on July 23,' showed scanty and cloudy urine on the right side, 
abundant and slightly hazy urine on the left side. 

Chemical anah'sis made by Giraudeau, was as follows: 

RIGHT KIDNEY LEFT KIDNEY : MIXED (BLADDER) 

Quantity 8 c.c. 28 c.c. 

Urea (per liter) 9.80 gm. 11.52 gm. 12.61 gm. 

This result proves that the left kidney secretes considerable urine, and that its elimi- 
nating function is excellent; while the right kidney secretes little urine and eliminates poorly. 

Tlie patient being in good general condition, is put on a regime of milk, diuretic 
waters, urotropin. Under this regime the pains diminished, but the urine is still cloudy. 

On September 28, general condition still good. In October, a radiogram was taken 
by Beclere, with negative result. On January 11, 1904, the patient is still in good condition, 
pain has .entirely disappeared. The right kidney is no longer palpable, but the urine is still 
cloudy. The patient remained in this condition an entire year. 

In January, 1905, he came to see me on account of the persistence of cloudy urine. 
At this time the patient was having occasional pains in the right lumbar region. 

In the belief that the right kidney function was good, and that his general condition 
was fair, I thought that pelvic lavage might bring about good results. The ureter was then 
catheterized with my direct cystoscope on January 19. A No. 7 catheter was left in place 
for nearly half an hour, and the urine thus collected was analyzed by Maute, with this result: 

Freezing point -1.01° 

Urea, per 1,000 c.c. 9.20 gm. 

NaCi " " " 6.50 " 

Sediment : Leucocytes in large number, especially polynuclear. 
Blood. 

Numerous pelvic cells. 

Very many microbes (bacilli and especially cocci, 
of which many are grouped in the form of 
streptococci) but which it is impossible to dif- 
ferentiate by direct examination; no tubercle 
bacilli. 

The pelvis was washed freely with boric acid solution and then with 1:1000 silver nitrate 
solution. Several lavages were given at eight-day intervals. The patient informed us that 
on the day when the lavage was given, the urine was very cloudy, but that it became much 
clearer and without the deposit on the second, third, and fourth days thereafter. The renal 
pains disappeared entirely after the first irrigation, and he no longer felt his former lumbar 
lassitude. 

At any rate, this direct method of treatment, though not absolutely radical, was carried 
on without any inconvenience to the patient. He was irrigated in the morning and he then 
attended to his usual occupation the rest of the day without suffering any inconvenience. 

Ureteral Catheterization — A Demeure 

The ureteral catheter left in situ (a demeure), may in some cases, 
facilitate closure of a lumbar fistula. I have seen the beneficial results 



IMtKTKIIAI. CA'I'IIK'I'KKI/A'I'IO.V A HK.M Kl ' KK 



325 



(>r this ])i-()C('(lur(' ill scn-ci'jiI Iiist.'iiiccs. One case is part icularl)- iiiler- 
esting-: A woman willi a iifclci-al stone, i-esultiii.H' in anuria and serious 
,i;'eiiei"al sxiiiploiiis. Tlie case was reporled hefoi-e the Siiry-ieal So- 
ciety.' 1 was conij)elle(l to do an eiiier<^-ency iiei)iirotoiiiy. Tlioug-li the 
patient felt l)ettei- and the stone had l)een removed l)y a uretero- 
lithotomy, the wound did not close, and a lumbar fistula persisted. 

A No. ^'2 catheter was iiit i-()(hiced throu'^li my cystoscope and left 
tliore. ImmediatelN- afterwai'd it was found that tlie kidiicv l)anda<i-e 




M p --e t 



Fig. 19S. — CoiiKenil:il liydroncphrosis resulting in an nlidoniinal renal fistula. 

was no longer being soaked with escaping urine, and it remained thus, 
absolutely dry; all the urine from the left kidney was being collected 
l)y the ureteral catheter. The latter was left in i)lace for seven days, 
and when it was withdrawn, tlie ])atient \-oided urine al)undant]v 
through the natural channels. 

In another case- of renal fistula cousecutiN-e to a congenital liy- 
dronei)lii-osis infected (hiring the course of typhoid fevei', I tliought 
the fistula might close and the normal function of the kidnev might be 
established by the introduction of a i)ermaiient catheter in tlie cor- 



326 CYSTOSCOPY AXD URETHROSCOPY 

responding ureter. I therefore inserted a No. 6 catlieter but quickly 
clianged it to a No. 9. Because of its large caliber, the latter could be 
introduced only with the aid of my direct cystoscope; in point of fact, 
no other catheter could bring about the desired result. 

Drainage was poor, because very little urine came through the 
catheter. On the other hand, all the fluid injected through the catheter 
came out immediately through the abdominal fistula. Because of this 
failure, I performed nephrectomy, and this was followed by the most 
satisfactory results. Figure 198 shows clearly that we were dealing 
with an infected congenital hydronephrosis. 

In true pyonephrosis, evacuation, and regular drainage of the 
pelvis can be accomplished neither by pelvic lavage nor b}" the perma- 
nent catheter. Surgical intervention is absolutely imperative. 

In aseptic uronephrosis, permanent catheterization is also inef- 
fective, because the catheter will inevitably infect the uronephrotic sac. 
In calculous anuria, catheterization can be recommended when it can 
be done quickl}- and easily. Krebs' succeeded in displacing a stone 
and provoked diuresis by injecting glycerin into a ureter, 

EEFEEElSrCES 

iBull. et mem. Soc. de ehir. de Paris, Feb. 15, 1913, p. 212. 

2Luys: Fistule renale abdominale consecutive a uiie hydrouephrose congenitale infectee an 
conrs d'une fievre typlioide, Neplirectomie, Guerison, La Cliniqne, Ang. 16, 1912, p. 517. 
sKrelis: Zur Tlierapie der Aunria Calculosa, St. Petersb. med. Wclinsclir., Xo. 52. 

Radiography of the Ureteral Catheter 

De Ilyes^ first suggested the introduction of a flexible metallic 
wire into the ureteral catheter in order to determine any abnormality 
in the direction of the ureter, or to locate the site of an obliteration 
in its lumen. A radiogram is then made, and the catheter, opaque to 
the roentgen rays is seen perfectly in the photographic plate. 

A very simple expedient is to place fine silver threads in the 
catheters. At present such opaque catheters are being manufactured; 
they contain a substance in their texture which stops the x-rays, thus 
making them visible in the plates. 

EEFEREiSiCE 

iDe lives: Ann. des nial. dcs organes geuitorinaires, 1902, p. 335. ' 

Pyelography 

Voelcker and Lichtenberg, combining ureteral catheterization with 
radiography, injected a seven |)er cent solution of collargol into the 



PYELOGIIAPIIY 327 

iiniioi- and pclxis 1 liroii- li a iirclcral callictci-. In lliis (-oiHlition, a 
radiooTniii is fakcii. 'riic jjclxis tliiis (lislcndcd l.y llic collaryol, gives 
a \-('r\- dcliiiiic ])i('1ui-(". This mdliod is known as pNclo^i-apliy. 

This procediiro is coinplcincid to llic dctci-iiiination of llic capacity 
of the pelvis. Tt is evident that iiicasui-einciit of tlie jjelvic capacity 
when pro])erly ])erformed, sliows (piickly and distinctly the degree of 
distention and the extent of the Jiydronephrosis. But wlien we desire 
corroboration, by the aid of a photographic picture, which makes a 
stronger impression on the eye, it is evident that ])yelograi»hv may 
render excellent service. 

Krotoszyner/ of San Francisco, uses solutions of cargentos in- 
stead of collargol. A 25 per cent solution, according to this author, is 
absolutely without danger, but he opposes the use of a 50 per cent 
solution on the ground that it may irritate the upper urinary tract. 

This author places the patient in the partial Trendelenburg posi- 
tion, injects the silver solution into the pelvis, and immediately makes 
the radiogram. He has obtained very exact information from the 
viewpoint of possible surgical intervention, through the use of this 
procedure. One of his cases is particularly interesting: 

A gardener, aged forty-one years, suffered constantly fioni left neiiliiiti'^' colic; pyelog- 
raphy made possible the diagnosis of a marked hydronephrosis. Nephrectomy confirmed this 
diagnosis ; the origin of this condition is of unusual interest. During the decortication, marked 
adhesions were found at the upper pole of the kidney; these adhesions consisted of abnormal 
blood vessels, which completely enveloped the ureter. 

This interesting case corroborates my opinion- that one of the 
principal causes of hydronephrosis is the pressure at the inferior pole 
of the kidney of abnormal l)lood vessels coming directly from the 
aorta. 

Fraidv Kidd' of London, who published an interesting work on 
pyeloradiography, particularly recommends this method of investiga- 
tion as a preliminary step to operations on the kidney. He believes 
that the collargol, cargentos, and other solutions employed, always 
cause a certain degree of renal irritation, and adds that a reallv ])a in- 
less agent is still to be found. 

He recommends a 5 per cent or 7 per cent solution of collargol, 
injected under low pressure. According to this autlior, jjyeloradiog- 
raphy should be done only by those cai)al)le of selecting the cases, 
that is, those cases in wliich an exploratory operation would (Uherwise 
be necessary. The risk is much K'ss witli this method than with an 
exploratory opei'ation. He also advises strongly against the practice 
recommended bv some authors of filling the same kidiu'\- three or four 



328 CYSTOSCOPY AND URETHROSCOPY 

times with strong solutions (15 to 50 per cent). [American urologists 
have had excellent results with a 15 per cent solution of Tiiorium, as 
suggested by Burns/ A splendid review of the entire subject of 
pyelography is given b}^ Braasch^ in his monograph of the subject. — 
Editor.] 

references 

iMartin Krotoszyner : Value of Pyelography in the Diagnosis of Hydronephrosis, California 

State Jour. Med., Nov., 1913. 
2Luys: A propos de la pathogenie et du traitement des hydronephroses, Tr., 10th session, Assn. 

fran^. d'Urologie, Paris, 1917, p. 122. 
sKidd: Pyeloradiography : A Clinical Study, Proc. Roy. Med. and Chir. Soe., London, 1913, 

vii (Surgical Section), pp. 16, 40. 
4J. E. Biurns: Jour. Am. Med. Assn., June 26, 1915, pp. 2126, 2127. 
■■■'Braasch: Pyelography, W. B. Saunders Co., 1915. 



PKACTK^AI. AI»PL1CATI()XS OK (*^■ST()S("()MV 

Thanks to the improvements brought ahont in i-ecent years, cystos- 
cop\' Jias made possible an admirable view of the mucous membrane 
of the bladder; but its limits are not restricted to the visual examina- 
iioii alone, for it has in addition, numerous therapeutic applications. 
Jf the mucosa and its lesions in their i)athologic state can be seen 
well, a suitable therapy can be arrived at. In this respect, direct vision 
c.ystoscopy surely shows its superiority, for it enables us to apply the 
treatment as well as to recognize the lesion. 

We will now take up the following subjects in succession: 
The treatment of vesical tumors, of foreign bodies in the bladder, 
of cystitis, of calculi of the ureteral extremity, and vesical biopsy. 

TREATMENT OF BLADDER TUMORS 

For a long time general surgeons and specialists have been trying 
to work out a precise formula for the treatment of vesical tumors. 
Hitherto suprapubic cystotomy alone seemed to meet this indication; 
at the present day, however, this view has changed entirely because 
the endovesical treatment of these tumors has come to be considered 
first and foremost, owing to the great progress that it has made. 

Indications for Suprapubic Cystotomy. — Suprapubic section is in- 
dicated only wlieii the ('n(h)vesieal method can not be applied ; i. c, w hen 
tlie urethra does not allow the introduction of large enough instru- 
ments, or when the size of the tumor to be extracted is too great. With 
this method there is an abundance of light and space to work in, and 
consequently large tumors with large bases can be readily reached. 

As to cancer of the l)hi(ider, when llie histologic diagnosis has 
been well established, there seems to be no particular advantage in 
excising the tumor by the suprapubic route, unless it is well circum- 
scribed and localized, from the very beginning, hi these eases, as in 
all cancel's, the affection is still local and sliouhl lie rctnoNcd 1)\- the 
suprapubic route. But when the walls of the bladder have already 
become infiltrated and the tumor has spread widely, it seems there is 
nothing to be gained by operating, because surgical intervention pre- 

329 



330 CYSTOSCOPY Al^B URETHROSCOPY 

cipitates further developments in the growth, much more rapidly than 
the natural and normal evolution of the disease itself. '*' 

The results obtained in the treatment of vesical cancer suprapu- 
bicalh^, with or without resection of the vesical wall, are not very en- 
couraging, and too deceptive to advise the employment of this always 
serious method. We may therefore conclude that the endovesical treat- 
ment of vesical tumors is the method of choice and that the suprapubic 
operation should be applied only in cases in which the preceding method 
can not be resorted to. 

Endovesical Treatment of Bladder Tumors 

The ideal purpose of the endovesical treatment of bladder tumors 
is to destroy the neoplasm by way of the natural channels without hav- 
ing recourse to the surgical opening of the abdomen. The endovesical 
method through the perfection of its highly specialized instrumenta- 
tion has won the approval of most urologists. Generally speaking, it 
may be said that this method can be applied to all benign tumors, which 
are not very large or widespread. The principal indication for this 
method will therefore be found in small papillomata. At the present 
time, it is considered neither rational nor reasonable to perform a supra- 
pubic cystotomy for a small vesical papilloma, and even for larger 
papillomatous masses. The endovesical treatment must be considered 
the method of choice. 

As regards cancerous tumors, neither the endovesical nor the su- 
prapubic method may be considered really curative. However, the 
former can be utilized much more successfully than any other method 
of treatment as a palliative measure. When the cancerous tumors are 
accompanied by profuse hemorrhages, which put the patient's life in 
jeopardy by their frequency or profuseness, it is of immediate benefit 
to attempt to control the source of bleeding by direct applications of 
adrenalin or by the use of the actual cautery ; but it goes without say- 
ing, this treatment is only palliative and symptomatic. 

The endovesical treatment can be applied by various methods, each 
having its own special advocates. These are as follows: Galvano- 
cautery, the cold or hot snare, electrocoagulation and sparking, elec- 
trolysis and radiotherapy. 

Galvanocauterization 

This can be applied in two ways; i.e., with the indirect vision 
cystoscope (Nitze's method) and with the direct vision cystoscope. 



TREATiMENT OF BLADDER TUMORS 331 

1. With the Indirect Vision Cystoscope (Nitze's Method). — The 
oiidovosical treatment of bladder tuiuors hy galvanocautei'izalion has 
been called the method of choice by Nitze, and iu a i-cmarkable Avork, 
Wo'iDrieh, of Berlin, has taken up its defense eloquently. 

Xitze' devised a sjDCcial cystoscope for the treatment of bladder 
{umors. This instrument was an ordinary cj^stoscope covered with a 
metallic sheet movable over the body of the cystoscope. Its extremity 
was slightly curved, with a galvanocautery attached to its concavity. 
This galvanocautery, spiral in shape, was made incandescent by the 
passage of an electric current. Over and behind the galvanocautery 
there was also a metallic snare which could be used either hot or cold, 
its operation being controlled by an outside wheel and shuttle-cock 
(Fig. 199). The whole constituted an instrument so large that it could 
be inserted into the male urethra only with great difficult3^ 

The ox)erative technic was to fill up the bladder, as usual, to in- 




Nitze's operating cystoscope. 



troduce the instrument according to the usual rules, find the tumor and 
apply the galvanocautery directly upon it. Sometimes the galvano- 
cautery was used, at other times the cold or hot snare. With the latter, 
masses of tumor were torn otf piecemeal at ditferent sittings, after 
which the tumor base was cauterized energetically with the galvanocau- 
tery. The pieces of tumor were left in the bladder to be expelled later 
with the urine. Bleeding occurred with this method, but these hematu- 
rias never assumed a serious character ; thej^ stopped after a rest in bed. 
I had the opportunity of witnessing Nitze use his instrument on a 
patient in Berlin, and I was convinced his instrumentation was dif- 
ficult and complicated even in the hands of its author. 

In addition this method had a serious disadvantage. The o])era- 
tion being performed through the fluid which distended the bladder, 
the platinum wire of the cautery had an imperfect incandescence, being 
immediately cooled by the presence of the water. Id order to obtain 
the total destruction of the tumor bv this method, it was therefore 



332 CYSTOSCOPY AND URETHROSCOPY 

necessary to employ many sittings. Finally another difficulty was 
encountered in maintaining the bladder fluid absolutely tran?^parent so 
as to be able to make an exact and precise application of the current 
upon the vesical tumor. 

However, the statistics furnished by Weinrich" of the applications 
by Nitze up to the end of 1904, comprised 399 cases of bladder tumor. 
Of these, 177 were malignant, 94 were benign and 128 could not be 
accurately classified, for want of tissue for microscopic examination. 

Of 101 papillomata operated upon by Nitze, he found no recur- 
rence in 71 cases, recurrence in 18 cases, and 12 cases were lost sight of. 

Recently, Marion^ attached a si3ecial cautery forceps to an indi- 
rect vision cystoscope for the treatment of vesical tumors, but its dis- 
advantages are the same as those of Nitze 's instrument; that is, it is 
complicated, pieces of tumor often remain adherent to the lens of the 
cystoscope thus obliterating the operative field, the vesical fluid must 
be changed frequently; these manipulations complicate and prolong 
the technic; the cauterization being made in water, it is undoubtedly 
less efficacious; finally, the attack on the tumor is always indirect, be- 
cause of the lenses which reverse the image, a fact that renders the 
treatment more complicated and difficult. 

Nevertheless this method can be utilized in special cases in which 
direct vision cystoscop}^ can not be done easily; for instance, when 
abdominal plethora prevents the unfolding of the bladder in the in- 
clined position of the pelvis. Direct vision cystoscopy does not give 
good results in stout patients. In some instances, I have been com- 
pelled to prescribe a preliminary reduction cure before I was enabled 
to bring about dilatation of the bladder in the inclined position. 

REFERENCES 

iNitze: Leliibuch der Kystokopie, p. 352. 

sWeinrieh : L 'Extirpation endovesicale des tumeurs de la vessie au moyeii du cystoscope 

opeiateur de Nitze, Tr. Assn. frang. d'Urol., 1905, p. 148. 
sMarion: Presse med., 1910, p. 961. 

2. Galvanocauterization with the Direct Vision Cystoscope. — 

Galvanocauterization of vesical tumors directly under the eye without 
the interposition of an optical apparatus and through a tube introduced 
through the natural passages, was first employed b}^ Griinfeld, of 
Vienna, with very primitive instruments. But this author has paved 
the way to an extremely interesting therapeutic method; unfortunately 
it is not sufficiently well known, nor is it used frequently enough, but it 
deserves the full attention of urologists because of its simplicity and 
efficiency. 



TKKA'r.MKNT OK I'.LA Dl (KI! 'ITMOKS 33o 

'^riicsc \('ry (|U,Mlili('S of siiiiplicil >• jiikI criiciciicy ;i11 raclcd iii\' Mttcii- 
lioii, ;ni(l I adoptc'd this method nearly ten yc.-ii's a.n'o; I hdicxc I have 
made it ically ])i*actical l)y the perfeclioii of the techiiic wliieli I have 
l)i-ou,i;hi al)oui. The direct vision cystosc()])e makes jralvanocaiitei'iza- 
lioii of hhuhh'T inmors hoth si]n])h' and ('ffieaeious. With this nu-thod, 
owins;' to modern im])rovements, the maiiipiihitions made directly under 
the eye arc carried out with a])Solute precision. The operation is per- 
formed in an air medium and the decree of cautei'ization tlius o])tained 
is much stroni^'er, more precise and moi'c Ihoron.iiii and the dni-alion of 
the a])i)licati()n is naturally nuicli shorter. 

Technic of the End-ovesical Treatment of Bladdeii Tr.Moits Wirn 
LuYs' Operating Cystoscope 

Before proceeding to the endovesical treatment proi)er, it is well 
if one is not particularly versed in the use of the direct vision instru- 
ment, to begin by examining the bladder carefully with an indirect 
cystoscope. The latter, having a large visual field, makes it possible 
to find the tumors easily and to obtain an exact general outline of the 
growth. After emptying the bladder completely with a catheter, the 
patient is placed in position with the pelvis elevated. This done, the 
direct vision cystoscope with its elbowed obturator is introduced; the 
tip of the obturator is then straightened and withdrawn. The aspira- 
tory tube of the cystoscope is put in operation and the lamp introduced 
and lighted. 

Following the indications found previously by the inspection of the 
bladder mucosa with the indirect cystoscope, we proceed directly to 
the places where the tumors are located. The cystoscope is advanced 
directly upon the tumor itself. With the left hand holding the cysto- 
scope steadily in position, the right hand introduces the thermocautery 
and places it in contact with the vesical tumcn-. The current is then 
turned on and the tumor is seen burning under our eyes. The fumes 
resulting from the burning are quickly evacuated by the air current 
which is maintained by the continuous action of the water puni]). 

In the case of papillomata, the tumor often l)ecomes attachcti to the 
galvanocautery as soon as the platinum wire begins to get red. It i)re- 
sents a picture resembling the arms of an octopus clasping the wire. 
Then we feel that the extremity of the cautery which is wedged in at 
first, has suddenly ac<iuired a certain frcedoni of nioNcnicnt, and if the 
cautery is withdrawn by stopi)ing the current, it will be found that the 
instrument is covered with i)ainllomata, which can be burned easily in 
the free air and thus destroyed in the simplest manner. 



334 



CYSTOSCOPY AND URETHEOSCOPY 



It is to be noted that vesical tumors are absolutely insensitive and 
that the patient feels no pain whatever under the action of liie burning 
platinum wire. When, however, the base of the tumor has been reached, 
the patient feels a distinct burning sensation. This is an important 
indication to stop the cauterization and thus avoid possible perforation 
of the bladder. 




Fig. 200. — Destruction by burning of a bladder tumor through the natural passages, done under control 
of the eye, with Luys' direct vision cystoscope. 

. By operating in this manner all possible complications can be 
avoided. At present I am using the galvanocautery only, having given 
up completely the use of forceps, which may cause hemorrhage Avhile 
removing pieces of the tumor. The use of the galvanocautery handled 
carefully, renders the destruction of vesical tumors thorough and 
certain, and seems to be absolutely devoid of danger. 

The treatment is concluded by returning the patient to the hori- 



TKKA'I'MKXT OF I'.I.A I )| )KI; TI.MOr.S 335 

zoiital position, llit' iiistruiucnt is willidrawii, tliu bladder is waslied 
witli warm lioric solution and a rest of one or two days is ordered, 

al(]i()u,i;li this is not a1)S()lutoly necessary. 

Advantacks of Exdovesical Treatment of Bladdfi; Tr.Moits W'liii 
LuYs' Operating Cystoscope 

1. The advantages of the endovesical method over the suprapubic 
are numerous. First of all, it is safe. Not only is the operative danger 
practically nil, but better still, patients do not have to undergo the 
inconvenience of general anesthesia, nor the prolonged stay in bed 
after operation. The treatment can be easily applied in the surgeon's 
office, without anesthesia, and the patient goes home after the treatment 
without any risk of danger; he also continues his occupation during the 
entire period of his treatment. For tumors of the bladder, this opera- 
tion is similar to lilhotrity in vesical calculi. 

Secondly, it is highly efficacious. Speaking of the endovesical opera- 
tion, Weinrich states it well when he says, "It is more radical than the 
suprapubic." This is an incontestable fact although it looks surpris- 
ing. It is well known that papillomata are often multiple and of small 
size. When the suprapubic operation is performed, a papillomatous 
mass of fairly large size can be easily recognized ; but the small growths 
may be hard to distinguish, because they hide themselves in the folds 
of the shriveled mucosa, so that the most careful and watchful surgeon 
is liable to close the bladder without having touched these small neo- 
plasms, which will eventually develop and cause recurrences. With 
the cystoscope the examining eye can see a well-stretched bladder wall, 
and no vesical tumor, however small, can escape observation. 

Finally, the facility with Avhicli the endovesical operation can be 
repeated, makes the treatment of tumor recurrences quite easy. The 
frequency of these recurrences, especially the papillomata, is well 
known; under these conditions it is manifestly impossible to jiropose a 
repetition of suprai)ubic section at very short intervals. In cancer this 
fact is still more important as the constant recurrence of this affection 
makes the endovesical treatment preferable. 

2. The advantages of my direct vision cystoscojx' over Xitze's 
operative cystoscope and the instruments similar t<» it, in the treatment 
of vesical tumors, are the following: 

It is very easily handled. Witli my cNstoscopr the images are 
direct and not inverted, so tliat tlie sni-geon's eye does nt)t reijnire spe- 
cial training to manipnlate tlie liand and the cautei'v. 



PLATE XXII 

Fig. 1. — Tumor of the roof of the Nadder necl:; tell- clap per appearance. 
This tumor, seen with the direct vision cystoscope, moved forward and 
backward under the influence of respiration, like the movement of a 
bell-clapper. 

Fig. 2. — Vesical fistula seen after a perforation of the bladder by an ad- 
jacent abscess, arising from a suppurating salpingitis; the abscess had 
ruptured into the bladder. 




Fig. 1. 




Fig. 2. 

PLATE XXII 



TREATMENT OF BLADDER TUMORS 337 

The action is more rapid and efficient. With Nitze's instrument 
the operation is performed under water which distends the bladder, so 
that the platinum wire becomes cooled by the fluid immediately, and 
therefore has a slower and less complete incandescence. With my 
cystoscope on the other hand, the operation is done in an air medium, 
and it can be readily seen that the cauterization will be stronger and 
more efficacious and for the same reason the duration of the applica- 
tion will naturally be much briefer. 

Results of the Endovesical Treatment of Bladder Tumors 

These results must be considered separately from the points of 
view of curative and palliative treatment. In benign tumors of the 
bladder, the endovesical method must be considered an absolutely and 
completely radical treatment. With this method the papillomatous 
mass can be fully isolated at the end of the cystoscopic tube and after 
a certain time under the action of the direct cauterization, nothing is 
left but a well-defined, bloodless, and shining scar at the former site of 
the raspberry-like tumor. Thus it can be said truthfully that a useful 
and complete surgical task has been accomplished. 

With my direct vision cystoscope all parts of the bladder are easily 
accessible; to reach the fundus, the handle of the instrument is ele- 
vated; for the right wall, the handle is pushed toward the left, and 
for the left wall, to the right. 

In cases of recurrent papilloma of the bladder which have come 
under my observation, the recurrence has never been seen at the site 
of the cauterization, thus proving the efficiency of this method of treat- 
ment. In a case reported (Case 13)^ the complete success resulting 
from this treatment was verified by cystoscopy performed three times 
by a colleague; there was no recurrence. In another case (Case 3) 
complete success was not obtained because the papillomata rei3roduced 
themselves in the form of seeds all over the bladder, but recurrence 
never appeared at the spots that had been cauterized. This case is 
still more interesting because the recurrence took place after a supra- 
pubic section. In Case 9, direct cauterization immediately and com- 
pletely stopped the very copious hemorrhages; these did not return 
for two years afterward. In Cases 12 and 14, the patients unfor- 
tunately could not be traced; but the direct cautery immediately 
stopped the bleeding in these cases. 

The following histories of cases are particularly instructive, be- 
cause they show the undeniable necessity and efficiency of the endovesi- 
cal treatment: 



338 



CYSTOSCOPY AND UEETHROSCOPY 



Case 1. — Recurrent Fapillomata of the Bladder Treated iy the Endovesical Method. 
M. S., male, aged forty-nine years, referred to me July 21, 1904, by my professor, Broca. 
The patient complained of considerable hematuria, paleness and generally weakened condi- 
tion. This hematuria had occurred four times in one year ; each time it haa lasted from 
two to six days, stopping sj)ontaneously after rest and milk diet. The hematuria for which 
he decided to have a consultation, had lasted four days. I first examined the bladder with 
the ordinary indirect cystoscope and discovered the presence of a small tumor, the size 








4 ^f^^^^A^S/r/. 



Fig. 201. — Vesical papilloma; microscopic section. 

of a large strawberry situated at the bladder fundus near the right ureteral orifice and slightly 
overlapping it. The rest of the bladder was perfectly normal. 

In view of the lesion being so limited, the suprapubic operation was decided upon. 
It w^as performed on July 26 by Broca, with my assistance. The extracted tumor was 
examined histologically at the faculty's laboratory of pathologic anatomy, by Decloux. 
The accompanying illustration (Fig. 201) which is an exact reproduction of a section of 
the tumor, shows a typical paj)illoma. 

The subsequent operative procedures were very simple. The bladder was quickly 



TItKATMKXT OF l;L.\l)IiKi; TUMOKS 339 

cliisril, llic mini' licc;iiiir ] ici' feci 1 y clciir, Jilid lllr |i;ilii'iit <|llil tlic ll(is|iil .'i I slinrlly :i t't('r\v;i nl, 
;i |i|i:i rciil \\ iMi icil. 

lie rcnijiiiKMl in lliis s:il isfactoiy (•(niditioii witli clear urine aii<l perfect <ieiieial lieallli, 
exactly mic yrai. On July '2'2, l!)()a, lie ict iirtie<l, cdiiiplaiiiiiig of slifflitiy liioixly urine, for 
three wei'ks jmst. l-^xaminnt inn with the (Jiilinaiy imlirect cvstoscope rcvcaleil the presence 
of three snnill pa |iilh)inal cms linilics iIm' si/.c (if small st lawliei'ries, situated r)n the rit;ht wall 
of the liladdei. A I the site nl' llie oiiiiihal tunnM- a distinct white scar was seen; there was 
no recurrence at that ]Miint. The heniatinia liein;^ sli};ht, tiie patient I'cfused treatnu'ut, 
remaining with the slight lihcdin;; till Octidjci, l!i(i5. At that time, on the advice of liroca, 
lie asked me to treat him locally thiough the natural passage. 

The first application with my direct vision eystoscope was maile Octoher '27. 'I'iie small 
|ia|iilliiniata were clearly disf inguisheil ; Hie fringes of each little tumor ha<l the form of 
halls of twine. Oii(> of these masses was isolated, lirought to the opening of the cystoscopic 
tube and luiiiicd with the galvanocautery. The point of the cautery that 1 iiseil at that time 
was very thin and narrow and did not allow much cauterization. At this first operation, tlie 
patient suffered no pain whatever; the second day he went about his usual occui)ation. On 
the following days he noticed that small pieces of burned tumor weic being eliminated with 
his urine; he brought some of the pieces to me. 

On November 6, at a second application of multiple cauterization, a few detached 
pieces were extracted with a special toothed forceps, this being followf^l by a slight hemor- 
rhage which was soon under control. Copious vesical irrigations with a warm boric solution 
and antipyrin, completely stopped the oozing of blood and the patient went home without 
ditSculty. For two days subsequently the patient had some hematuria, which kept him in 
his bed. Blood clots formed in the bladder, which were aspirated through a large metallic 
tube. Soon the hematuria stopped completely, the urine became clear and remained so. 

It is worth noting that the postoperative hematuria was undoubtedly due to tlie trac- 
tion of the forceps and not to the galvanocautery. Since that time, I have aliandoned the 
use of the forceps completely. A third examination showed only two jjapillomata left ; 
they were also destroyed by the cautery. 

The patient remained in excellent condition with clear urine and no tiace of lilood 
for many months. In February, 190G, desiring to verify his condition, although in good 
health, I examined his bladder with the indirect eystoscope, and found a new croj) of small 
pjapillomata. These did not recur in the cauterized places, but were spread about like seeds 
in various parts of the bladder. Some were like a pin head, others a little largei like grains 
of hemp seed ; the latter were situated on the superior part of the bladder neck, adjacent to 
the base of the prostate. They were burned with an improved model galvanocautery. 

The cauterization of these paj^illomata situated on the superior aspect of the bladder 
neck was facilitated by instructing the patient to make pressure on the upper bladder wall 
with his hand; thus the tumors were pushed into the cystoscopic tube, making their destruc- 
tion extremely simple. To determine the result obtained after burning, the iiatient rehixes 
the vesical wall and the scars are examined in profile. 

The patient remained in perfect health with clear urine for more tlian live months. 
In November, 1906, he came back for examination although he was without any mor1>id 
symptom. I found another proliferation in sjiots not treated liefore. These also were 
cauterized in the same way. In Februar.y, 3907, still another examination was made, with 
additional cauterization of new growths. The general and local conditions continue satis- 
factory. I see the patient regularly once a year. 

In point of fact, the patient has not seen any further blood in his urine since the 
endovesical. treatment was begun, a period of more than ten years, in spite of continuous 
recurrences of the papillomata in various spots. This is due to the fact that the endovesical 
treatment prevented the development of the papillomata and their sul)sequent hemorrhages. 
Finally, a detail which might be interesting in a general way; in August, 1907, this patient's 
daughter consulted me for a small papillonm of the face, which I burned at once witli the 
galvanocautery. 



340 CYSTOSCOPY AND URETHROSCOPY 

Case 2. — Tumor of the Bladder Treated Endovesically. Mrs. M., aged sixty-five years, . 
referred to me by Broca, in May, 1907, for severe hematuria. The patient li|i^d slight bleed- 
ing attacks for three years. She decided to seek medical advice because her health was 
being jeopardized. When I first saw her, the urine was extremely bloody, so that indirect 
cystoscopy was impossible. In spite of repeated irrigations and washings, a distinct view 
could not be obtained. On the other hand, using my direct vision cystoscope, I immediately 
found a tumor the size of a walnut, parts of which were necrotic. It was situated in the 
median line of the bladder fundus, stretching toward the left lateral wall. The right lateral 
wall was perfectly noimal. I cauterized the tumor in three different sittings, with truly 
remarkable results. The hematuria stopped completely, the urine became absolutely clear, 
and the frequency in urination, which before my intervention was hourly by day and 
every two hours at night, was perceptibly ameliorated. Subsequent to June 7, she urinated 
only every three hours during the day, and not at all during the night. The vesical capacity 
at the beginning only 80 c.c. was increased to 200 c.c. 

Finally, the general condition which was almost cachetic, improved rajsidly, and the 
patient was enabled to attend to her usual duties without undue fatigue. I saw her again 
in September, 1907, and found that she was maintaining her excellent health. Cystoscopy at 
that time revealed a small recurrent tumor the size of a pea situated at the site of the 
former growth. This was immediately cauterized with the galvanocautery. 

As in the former case, I advised the patient to come for examination every six months, 
so as to prevent possible hemorrhages caused by proliferations of the tumor. 

Case 3. — Tumor of the Bladder Treated hy Galvanocautery thro^igh the Direct Vision 
Cystoscope. Mrs. S., aged sixty-eight years, referred by Stora, October 19, 1910. She com- 
l^lained of passing dark and bloody urine occasionally, sometimes of a blackish color. Cystos- 
copy showed a normal bladder, l^ut behind the left ureteral orifice a raspberrj'-like tumor the 
size of a cherry was revealed, which was evidently a papilloma. All trace of this growth 
disappeared completely after three cauterizations through my direct vision cystoscope. 

Case 4. — Papilloma of the Bladder Treated hy Galvanocautery Through the Direct Vision 
Cystoscope. Mrs. C, aged twenty-seven years, referred to the genito-urinary clinic of Ba-oca 
Hospital, by Eobineau, March 8, 1912. The patient complained of" intermittent attacks of 
pain in the left kidney region; her left kidney was lower than normal and the -urine was 
cloudy. Eobineau thought of a left pyonephrosis, and wanted me to make an examination of 
the separate urines of both kidneys. When I cystoscoped her, on March S, I was greatly 
surprised to find a tumor of the bladder with the typical aspect of a ijapilloma situated 
near the left ureteral orifice. It is highly probable that this villous tumor was pressing upon 
the left ureteral orifice so that it caused a difficulty in the evacuation of the left ureter and 
kidney, and to a certain extent caused the pains in the left kidney. 

I cauterized the tumor with my cystoscope three times ; i. e., on March 15, 23, and 30. 
The growth disappeared entirely after this intervention. This tumor is well illustrated as 
it appeared when first examined on March 8, in Plate IX, Fig. 4. In Plate IX, Fig. 2, 
the same tumor is shown as it appeared after the first cauterization. 

I saw this patient again a year later, that is. May 30, 1913. At that time, she com- 
plained of cloudy urine and was anxious to know whether the vesical tumor had recurred. 
The examination showed that she was suffering from a gonorrhea which she had contracted 
from her husband. The external orifice of the urethra was extremely edematous; the cloudy 
urine was due to a purulent urethral discharge, the fundus of the bladder was inflamed ; 
besides, she had a severe bartholinitis. Antigonorrheal treatment was instituted and after 
the acute stage had passed, I examined her (June 6), but did not find any trace of the 
vesical tumor. Another cystoscopic examination in February, 1914 (two years after the 
first treatment) showed no trace of any lesion. 

Case 5. — Tumor of the Superior TT'all of the Bladder Nech Treated With the Direct 
Vision Cystoscope. Mrs. B., aged forty-one years, was seen on June 13, 1913, at the urinary 
clinic of Broca Hospital. She complained of cloudy urine and frequency of urination both 



Tl'vKAT.MKXT OF ISLADDKU TI'.MOKS 341 

by day and iiiglit. On oxaininnt imi llir hlidilcr capacity was found reduced to aljout 100 
('.('. TIh' urctluii was small ami lilnnus ami tliis made tlic passaj^e of the cystoscope quite 
ilit1i.-iill. 

However, llic instrument was introduced and it was found that she had a severe gen- 
eralized cystitis. But -while the cystoscopic tube was being withdrawn, a tumor was seen 
immediately behind the neck, hanging from the superior wall and acting like a valve to the 
extremity of the tube. The growOi disappeared completely after two apjdications of the 
galvanocaufcry. The lumor is well illustrated in Plate XXII, Fig. 1. 

Subsequently she was treated with renal lavage for a loft pyonephrosis. I examined 
her again seven months later and found no trace of the tumor. The report of these cases 
shows conclusively the value of galvanocauterizatioii with my direct vision cystoscope. 

The following case of vesical tumor destroyed through the natural 
passages- was reported by Caspari, of Lausanne: 

' ' I would like to call attention to a very simple instrument tliat I have found very use- 
ful; i.e., Luys' Direct Vision Cystoscope. I have used it with considerable success in the 
following case : 

"Mrs. M., aged forty-six years. Menstruation ceased in September, 1905. On the 
morning of August 10, she became frightened at the appearance of a large quantity of 
blood in the urine. She had ' ' lost her blood, ' ' as she termed it, two years previously. An 
eminent gynecologist was consulted but could not determine the source of the hemorrhage, 
as.it had ceased when she came to hini for advice. An 'exploratory' curettage was pro- 
posed, but not accepted. In the present instance the blood came during micturition. Nothing 
abnormal was found in the genital tract. I cystoscoped the patient in the afternoon of the 
same day, using the indirect cystoscope. There was no hemorrhage at that time, the urine 
being perfectly clear. I immediately found a papillomatous tumor on the left lateral side of 
the bladder fundus. 

"It began at the left ureteral orifice, which was obscured by a few villi, and extended 
thence outward and backward nearly four centimeters from this orifice. It was as large as 
two big superimposed raspberries. It was shaped like a mushroom the cap of which was 
oval and its surface uneven with well-marked villosities floating in the fluid like the arms 
of an octopus. The pedicle of the tumor, hidden behind the mass, was rather imagined than 
actually seen. It was, in fact, elongated from within outward and anteroposteriorly ; the 
mass was oval like the surface but its dimensions wore much smaller. Tlie rest of the bladder 
was normal. I photographed the neoplasm with the photographic cystoscope, but the result- 
ing picture was unfit for reproduction. 

"The tumor being well localized and isolated, and undoubtedly papillomatous and 
benign, I decided to destroy it with Luys' cystoscope through the natural passages. The 
result was complete and perfect after three applications at various intervals. Tlie patient 
was cured without any complications whatever. She did not stay in the hospital, but attended 
to her usual occupation and enjoyed all the pleasures to which she was accustomed. Eighteen 
days after the second cauterization, I made a control cystoscopic examination with the indirect 
cystoscope. The following was noted : 

"The tumor has disappeared completely, except a small round granulation situated at 
the external extremity of the surface occupied formerly by the tumor. Tliis region itself 
can hardly be distinguished from tlio rest of the vesical mucosa; there is a very slight cicatri- 
cial appearance in the form of a line corresponding to the original insertion of the neoplasm. 
This line, staiting from the ureteral orifice extends outward and slightly backward up to 
the above mentioned granulation. As a precaution I cauterized this granulation also. 

"Cystoscopic examination, a week later, showed tliat the tumor did not exist any 
longer; the original site was represented only liy a darker cnloratiiui of the mucosa. The 
technic employed was the one described by Luys. ' ' 



342 CYSTOSCOPY AXD URETHEOSCOPY 

[The editor has assumed the responsibility of omitting the rest of 
this report, inasmuch as it is an exact repetition of the antl^or's discus- 
sion on the technic advocated by him in the treatment of vesical tumors. 
Caspar! 's conclusion follows. — Editoe.] 

' ' The endovesical method seems to be the method of choice when we have to deal with 
benign tumors of the bladder, of small size and not very numerous ; also for the frequent 
recurrences of these tumors. In the female, Luys' method must certainly be given prefei'- 
ence because of the excellent results obtained. I am happy to be able to assist in making it 
better known, having been the first to cure a case in Switzerland with. this method." 

In addition to these very characteristic histories, we may cite also 
the interesting work upon the same subject by Tixier and Gauthier, of 
Lyons. ^ There are also two interesting reports by de Keersmaecker, of 
Antwerp,* on the extirpation of bladder polyi^i through the cystoscope. 

CoisTTEAIXDICATIOXS TO THE El^DOVESICAL TrEATMEiSTT OF BlADDER 

Tumors 

If endovesical cauterization is the method of choice for all small 
tumors of the bladder, and especially j)apillomata, I must say it can 
not be considered a radical treatment in the large and malignant tumors 
with wide and infiltrated bases; also in obe.^e patients in whom the dis- 
tention of the l)ladder can not be obtained on account of the consider- 
able abdominal iDlethora. In these cases, Nitze's operating cystoscope 
should be used. 

In conclusion, the endovesical treatment of bladder tumors with my 
direct vision cystoscope is to be recommended, for its remarkable effici- 
ency and benign character."' Up to the j)resent time, I have made over 
fifty applications of this method in men and women, in some cases often 
repeated, without a single untoward incident. 

REFEEEi^CES 

iLuys: 2d Congress, German Urological Society, Berlin, 1909, p. 435. 

-Communication to the Vaudoise Medical Society, meeting of Dec. 4, 1909, also La Clinique, 

1910, p. 25. 
sTixier and Gauthier: Societe des Sciences medicales, June, 1911. 
4De Keersmaecker: Societe beige d'Urologie, June, 1905. 
■■iCaspari: Traitement des tumeurs de la vessie. La Clinique, 1910, p. 25. 

Treatmex^t of Bladdee Tumoes AVith the Cold oe Hot Sx^aee 

This method of treatment A\as employed by Xitze, as ^^I'^viously 
stated; but he used this method only as a preliminary step in the gal- 
vanocauterization of bladder tumors; he snared the tumor first and 
then he cauterized the pedicle. 

The method of Blum, of Vienna,' is entirely different. This author 



TIM'.A'r.MKXT Ol' l',I,.\l)IiKi; TCMOllS 






lias |)iil)li.-li(M| a sci'ics (tf iiilci'csliiii;- n'|)()its on lii> iiidliod, wliidi lia> 
i^'ivcii splendid icsuHs.'' Xilzc's Insi rnniciii consislfMl cssciilially of a 
)'i,<;'i(l syslcin, w liidi dillVi-s coinplctcix- from llic llcxihlf system |»i-()- 
])()se(l l»y I5lnni. 

()tliei- anlliors, pi'eccdini; lilnni. liki- Schlauinl wcil, l-'faidc. and 
Boliine,'' had coiiceixcd llie idea of n^ini;- IIm' eat iielerizin;;' eysloseojx* 
as an ojx'i'atini;' in>t iiinient. hut IJhini w a> the lirst to (h'\'ise a ])i'a('- 
tical a])])ai'atus, whiieh thn>oj)ene(| a new patii\\a\- lo endoNcsical opera- 
tions. 

I'hini's instiunient can he inti-odueed into the eatheteri/.iiii;- cyslo- 
s('0])e in the same way as a ureteral eatiieter. To ])oiiit the snare to- 
ward (lilTei-eiit poi-tions of iIk^ l)ladder, lie utilizo Alharran's defleetor. 
The essential element of liliiin's instrument is a. snare eiivelo])ed hy a 




Fig. 202. — Eliini's operating cystoscope. 

Ilexihle ]netallie slieet, which ean he inti'odueed in its entirety into tlu' 
eliaimel proxided foi- the ur(-teral catheter in the catheteri/ini;' cysto- 
scope. 

Blum's opei-ating instrument (Fi.u'. 202) is composed ot" a steel 
sprino- 1.8 mm. wide, correspond in.-^- in caiiher to a Xo. G Cliarriere. This 
is the condnctini;- channel For all the instruments. This s])rin,u' of steel, 
very Ilexihle and free, lias a solid, strai<;ht end that is stroiiii' enon.u'li 
to resist i)ressnr(» u])on aii>- part of the vesical nmcosa, as for instance, 
the base of the tumor. The sprini.;- 1ias an eye at its vesical end, to 
Avliicli a bronze aluminum wii-e is attached: the other extremity is at- 
tached to the end of the ohtui-atoi' which can ht' inserted or withdrawn 
within the himeii of the spiral in ordei' to enlarge or diiiiinish the snare. 



PLATE XXIII 

Fig. 1. — Edematous aspect of a ibreteral orifice; undoubtedly indicating a 
diseased condition of the ureter or of the corresponding kidney. 

Fig. 2.-^Edevia of the ureteral orifi,ce observed iii connection with a ureteral 
calculus. 




Fig. 1. 




Fig. 2. 

PLATE XXIII 



TREATMENT OV Br.ADDKn TTMOHS 34.") 

The calilx'f of Uic cxtcnial cxti'diiilx ol' the spi-iiii;- is siifliciciit to 
allow the stool ohturaloi- to coniplctcly close its liiiiicii. Tlic iiitcnial 
extremity lias a semilunar grooxc in wliicli ilic snni-c is fully lodgcMl 
Avlieu reduced to its minimum size. 

The niaiii|tula1i()n of lliis inslnniiciil is racililalcd lt>" llic use ol" 
LeiterV diuiii linndlc; lliis lias a llai sju'inx, oNcr tlie external exti'ein- 
ity of Avliicli the obturator is rolled. The i)lain snai-e can be replaced by 
a forceps wliicli is operated by llie ol)turator and the di'um handle. 
Zuckerkandh of A'icnna, lias devised a special caulcM-y which can be 
attached to this instruinent; it aids ii! Ihc caidcri/alion of the base oi* 
the tumors. 

Preparation of the Patient. — Blum anesthetizes the anterior and 
posterior portions of the nrethra wi-tli three or fonr c.c. of a 5 per cent 
solution of novocaine. Sometimes in sensitive patients he injects liypo- 
dermatically two c.c. of morphine, or he "-ives the patient an antipyrin 
irrigation. After the bladder is emptied, he instills five c.c. of a 1 :1000 
solution of adrenalin, to prevent bleeding-. (This dose of adrenalin 
seems quite strong and dangerous.) Finally, to obtain the clearest pos- 
sible vision, the bladder is filled with 250 to 300 c.c. of sterile water. 

The quantity of water to be injected varies according to the indi- 
vidual. Blum has noticed that in tumors on the roof of the bladder 
or on the anterior wall, it is advisable to inject a smaller cpiantity of 
water, so as to bring the cystoscope to a more convenient distance. 
Thus in a man eighty years old, with a pai^illoma on the roof of the 
bladder, he employed the following jirocedure: With 150 c.c. of water 
in the bladder, the tumor Avas so far away that he could not grasp it 
with the snare. He then opened the snare so widely that the largest 
circumference of the tumor could easily be enclosed by it. Then he 
gradually emptied the bladder till thirty or forty c.c. remained. In 
this Avay, the vesical tumor descended spontaneously into the snare 
and was thus extirpated. 

Preparation of the Instrument. — The operating instruments are 
attached to Xitze's catlieterizing cystoscope. The bronze aluminum 
wire constituting the snare is pulled so that it assumes the sha]ie of 
the letter U, one centimeter in length; this is completely hidden in the 
concavity of Albarran's deflector. The iiislrunieid is i-.ow introduced 
into the bladder. 

Operating' Technic. — AVhen the tumor ai^i^ears in the visual Held, 
the spiral spring is ijushed inward until its extremity is seen: then the 
loop is formed in a circle, the diameter of which sluudd be a little 
larger than the greatest circumference of the tumor. The s])iing is so 
manipulated that the loop is perpendicular to the length of the tumor. 



346 CYSTOSCOPY A2^D URETHROSCOPY 

With the aid of Albarran's deflector, the Ioo^d is brought around tlie 
tumor and the spring is pushed to^^'a^d the vesical wall so that it 
presses upon the normal vesical mucosa. 

When tlie looj) is at the base of the g^o^vth, the ol)turator is jDulled 
forcibly. During this maneuver a sensation of crackling of the de- 
stroyed tissues is often felt. It is important to make sure that the 
loop is firmly attached to the pedicle, for then the tumor will follow 
all the movements of the sx)iral. 

After fixation is tlius secured, the cystoscope is withdrawn leaving 
the spiral and the snare in the same manner that a ureteral catheter is 
left in the ureter. The snare is left in this position for 24, 36, or 48 
hours, when it usually comes out spontaneously. Sliortly thereafter the 
patient generally passes the entire tumor with the first micturition. 

It is well not to cystoscope the patient for eight to fourteen da^^s 
after this operation, on account of possible hemorrhages. But if it is 
done, an ulceration will l)e seen at the site of the former growth, in the 
form of a crescent covered by necrotic tissue. Fifteen days after opera- 
tion the eschar usually comes out spontaneously, accompanied by a 
slight hemorrhage. In this way, the destruction of the tumor is at- 
tained at one sitting without the loss of a drop of blood. This is cer- 
tainly an ideal technic for a simple operation ; but often certain difficul- 
ties are encountered. 

The operative difficulties, are the following: First the tumor can 
not be grasped as above described. In this case the double catheter- 
izing cystoscope should be used. The spiral and snare are passed into 
one of the channels, and a toothed-forceps into the other. The forceps 
grasps the tumor and the snare is worked around the growth as close 
to the base as is possible. 

Other difficulties are due to the indirect cystoscope itself, the 
principal being that the vesical fluid becomes cloudy. Finally, serious 
hemorrhages are always to be feared, particularly when the eschar 
separates and comes avray. 

Operative Results. — Blum has operated on 44 bladder tumors of 
which 37 were papillomata. In one case he was compelled to resort 
to suprapubic cystotomy because of a A^ery dangerous hemorrhage 
which followed the seiDaration of the eschar. (This occurred eight or 
fifteen days after the endovesical operation, while the operator was 
cystoscoping the patient in order to verify the result.) In all the 
ether cases the endovesical operation was successful. Two cases 
recurred and were again operated on in the same way. Blum prefers 
the cold snare because the hot snare might burn and perforate the blad- 
der wall. 



TKKA'I'MK.Vr (H- l!L.\l»l>Ki; 'IIMdltS o47 

]:i:ri-:i;i;x('K.s 

ir.liini. X'ictur: I'lin iiciii's iiit lavcsikali's ()|n'inl iohs vrrfidm'ii. Ztsi-lic. f. rrol.. I'.in'.i, iji, ll(i. 

-Illiini: /tsrhr. f. I'lnl.. I'.H 1. p. Sl'A. 

-liuliiiic. I>'iil/.: Ziir 'rnliiiil^ dcr iiil r:tv('sik;ilcii Opi'iat inn \(iii liUi.-iciil ui.Kircii, Zts<-lir. f. Urol., 

I'.MI!>. iii. .".III. 

P]lecti;()('().\(;ii..\i'I().\ ok Ti'.moks ok tiik Iji.addku 

'^^riic li'caliiM'iit of hiaddcr tiiinors by clccl KO('oa,i;iilalioii lia.< Ix'cii 
iilili/cd ))ecaiiso of llic splciidi:! it'sull.< oMaiiKMl with this inetlio«l in 
luiiiors on aooossihlc jjaits oT llic hody, liy DoycMi' in France, Bei'iidt, 
ill Ansti"ia, and Xa.iiolselmiidt-' in GerniaiiN'. Doyen'' first makes a supra- 
|iiil)i(* incision and llirou^li lliis opciiiiii;' in tlic bladder lie apjilics clc;-- 
troeoa,i>,nlation to the tumor. 

Edwin Beer* of Xew York, in 11)10, eoneeived tlie idea of applyitift' 
electrof'oa,i;ulation to bladder tuiiiois llirouft-li tlie natural eliannels. 
lie nscd tlic indirect cystoscojx'. A number of Americans shortly after- 
ward ])ublished eases confirming' the value of this method. 

Among the most noted publications may he mentioned those of 
Buerger and Wolharst,' Gardner,'' Sinclair,' McCartliy,- Judd,'' Harps- 
ter,'" Binney,^^ AVatson,'- Pitcher,^' and Barney." Reports have also 
l)een pul)lished hy Bachrach,^'' in Austria, Kuttner,^'' Bucky and 
Frank, ^' in Germany, and in France by Legueu,'^ Jfeitz-Boyer and Cot- 
tenot," Andre-° and Lepoutre and d'Halluin.-^ 

Electrocoagulation is produced by high-freqnency currents of loir 
tension; while the spark produced by the high-frerjuency current and 
Itif/li tension Avhich constitutes "fulguration," exerts but a supei-ficial 
action, and no effect deeper than three or four luni. Doyen has deiiion- 
strated that with the high-frequency spark and low tension, electro- 
coagulation can be ol)tained in the substance of the tissues to a depth 
of fifteen to twenty mm. 

The cni'rent nec(^ssary for electrocoagulation is secured through 
a special current transfoi'mer (Fig. 203). 'This a])])aratus is com])osed 
of a transformer Avhich changers the street current with its high voltage 
running up to se\-eial luillioii volts. Tliis cui-rent ]tasses into Oudin's 
i-esonator; a tliird part I'egnlates tlie intensity of the cnri-ent. 

Si^arking is not absolutely essential lor electi-ocoagulation. Tf 
instead of lea\ing a ga}) between the elect I'ode and the tumor, tlie two 
are brought into direct contact, coagulation will be ])ro(luced without 
carbonization, because its action is not due to the heat alone. 

When the electric current is not very strong, and it is used with 
very large electrodes having (Mjual surfaces, "diatliei-mia" oi' "theiino- 
lienetration" is ])roduced; this sini])ly produces a sensation of heat. 



348 



CYSTOSCOPY AND URETHROSCOPY 



When a stronger current is used and the electrodes have a very much 
smaller surface, the albuminoid matter is coagulated and we-have ''elec- 
trocoagulation. ' ' 

To j)rodiice the maximum effect two electrodes are required, one 
being very large and wide and the other very small. A sensation 
of heat will be produced near the large electrode, because the heat is 
spread over a large surface ; on the other hand, the maximum electro- 
coagulation will be obtained near tlie small electrode. In practice, 
the wide indifferent electrode consists of a sheet of tinfoil placed under 
the buttocks of the patient, and the small active electrode is introduced 
into the bladder in direct contact with the tumor. 

The small electrode consists of a perfectly insulated copper wire 




BEESL\UER - LOWE\STEI\ - PARIS 

Fig. 203. — Current transformer for electrocoagulation. 



Jiaving a copper tip at its end, which comes into contact with the 
growth. Its caliber is not quite that of a ureteral catheter, being easily 
passed into a catheterizing cysto scope and much more easily into a 
direct vision cystoscope. 

RBFEREN-CES 

iDoyen: L 'electrocoagulation, Tliird International Congress of Physiotherapy, reports and 

communications, pp. 556-560. 
aNagelschmidt : Effets thermiques produits par les courants de haut frequence, Archives 

d'electricite med., March 10, 1910, pp. 161-173. 
sDoyen: Therap. chir., Paris, 1910, iii, 71. 

•iBeer: Jour. Am. Med. Assn., May, 1910; also Med. Eec, New York, Feb. S, 1913, p. 242. 
sBuerger and Wolbarst: New York Med. Jour., Oct. 29, 1910. 
6G-ardner: Am. Jour. Deimat. and Genito-urin. Dis., January, 1912. 
^Sinclair: Am. Jour. Urol., March, 1912. 
sMcCarthy: New York Med. Jour., Sept., 1912. 



TREATMENT OF l'.l.AI»|)l-:i: TCMOIIS 349 

fljiuld : Jour. Am. ^Mcil. Assn., November, ]!»12. 
loHarpstcr: Am. .Iimr. Surg., Jan., 1913. 
iiBiniifv: Jioston Med. and Surg, Jour., Feb., l!»i;'.. 
)->Wats()ii: Urcd. and Cutan. Rov., Fel)., 191:',. 
'■'•Pil(dier: Am. Jour. Surg., April, 191. '5. 
1 'Barney: Boston Med. and Surg. Jour., .July, 191.".. 
i^Bachracli : [''olia Trologica. .liily, 19i:i. 
i«Kuttner: Internat. Cong. med. Sc, Lcjiidoii, Aug., 191;!. 
I'Bucky and Frank: Miinch. med. Wchnschr., Feb., 191.".. 
I'^Legueu: Arch. urol. de la clinique de Necker, I'ari.^. 19i;;, i. 
mlloitz-Boyer and Cottenot : Assn. d'urol., 1911, p. 771. 
-oAndre: Assn. frane. d'urol., Oct., 1913, p. 736. 
2iLepoutrc and d'Halluin: Eev. clin. d'urol., Jan., 1914, p. .".o. 

Operative Technic. — Tlie tuclmic will vai-y a'-( oi'diii;^- to wlielJier 
the indirect or direct cystoscope is used. 

1. With the Iistdirect Method. — The patient is placed in ilic nsnal 
])Osition for indirect cystoscopy. Tlie hhnhler is tilled witli :2(J0 c.c. of 
sterile water and the electrode is introduced in the same manner as a 
ureteral catheter, under control of the eye, and In-ouft-ht into direct 
contact with the tumor. The current is turned on for fifteen to thirty 
seconds, at each application; the changes produced by the action of the 
current are kept under close Avatch all the time. At first gas hubbies 
will appear, then the tumor will show a ])lack central zone surrounded 
by a whitish coagulated area. 

Generally the treatment must be interrupted because the vesical 
fluid soon becomes cloudy. In this case the cystoscope is withdrawn 
and the patient is instructed to urinate; considerable broken-down 
debris of the coagulated tumor will be found in the urine thus passed, 
[In the improved American cystoscopes, cleansing of the bladder is 
accomplished by merely removing tiie telescope and irrigating tlie 
bladder through the cystoscopic tube, which remains undisturbed 
throughout the treatment. — Editor.] 

2. With the Direct Method.— In general, the technic is the same 
as that in direct vision cystoscopy. The patient is placed in the in- 
clined position, a large indifferent electrode is placed under the but- 
tocks, the cystoscopic tube and the lam]) are intioduced and the small 
electrode is directed upon the tumor. 

There is a decided difference in the application of electrocoagula- 
tion between the two instruments, tiie direct vision method having 
distinct advantages. The fluid distending the l)la(lder will offer greater 
resistance to the current than that offered by the air, as in the direct 
vision method. Furthermore, the electricity will produce a certain 
amount of decomposition of the water, wliicli is made evident by the 
escape of gas bubbles and by numei'ous small explosions during the 



350 CYSTOSCOPY AN^D UEETHEOSCOPY 

coagulation. According to some autliors, tliese explosions are of no 
consequence; nevertheless, altliougli the patient is not aware of them, 
they impair the clear view of the operator to some extent at least. 

With the direct cystoscope, the technic is therefore much more 
simplified because these water inconveniences are not present in the air 
medium. With this instrument, a tumor of the bladder may be con- 
sidered outside of the body, and can therefore be treated like any other 
tumor of the cutaneous surface. 

Certain j)recautions are necessary, however, when this instrument 
is used. First, the tumor surface must be thoroughly anesthetized, 
by the aiDplication of tampons soaked in a 10 per cent solution of 
stovaine. After a few moments the active electrode may be safely ap- 
plied, providing, however, that only weak currents are employed. 
When the current is too strong, the patient will suffer pain and moves 
about uneasily, so that the operation can not be contiimed. 

On the other hand, when the anesthesia is thorough and the cur- 
rent weak, electrocoagulation can be done painlessly, but the opera- 
tion progresses slowl}^ and the sittings must be lengthy, with little to 
be done at each sitting. With patience, however, the results obtained 
are worth while. In particular, there is no bleeding. The electro- 
coagulation produces a very Avliite eschar which penetrates deeply, 
and the base of the tumor can be attacked safely without fear of in- 
jury to the bladder wall. 

It can thus be seen that a large tumor can not be destroyed in one 
sitting. It is better by far to employ repeated sittings to insure its 
complete destruction. 

Eecentl}^ I used this method in a female iDatient at Broca Hospital, 
in the service of Jeanselme. She complained of cloudy urine. C^^stos- 
copy revealed a tumor (Fig. 204). Electrocoagulation was performed 
with my direct vision cystoscope, under most favorable conditions. 
The changes and final results of the treatment are Avell shown in Figs. 
205, 206, 207, and 208. 

Comparative Value or Electrocoagitlatiojst and 
Galvanocauterization 

Unfortunatel}^ the comi^arative therapeutic A'alue of these two 
methods has not yet been sufficiently studied, and it is interesting to 
consider which procedure is to be preferred. 

Advantages of Galvanocauterization. — 1. It is simple. The use 
of the cautery is very simple. A galvanic current can be provided 
easily in any surgical equipment. The manipulation of the current is 



THKATMEXT OK IJI.ADDKK TTMOItS 



351 




Fig. 204. — \'ie\v of a bladder tumor situated in median line of the trigone, — before treatment. 

SO simple, so convenient, tliat it constitutes an ideally simple tlieraiieu- 
tic agent. 

2. It is safe. The galvanocantery is so thoronglily under con- 




Fig. 205. — Same as Fig. 204. First application of electrocoagulation. With the direct vision cystoscope, 
the excavation made by the burning at the base of the tumor is easily seen. 



352 



CYSTOSCOPY AND UKETHROSCOPY 




F;g. 206. — Same as Fig. 204. View of the same tumor eight days after the first application of electro- 
coagulation. The apex of the tumor is lower and much smaller in front. 

trol that it is impossible to cause injury to tlie bladder mucosa. Neither 
perforation of the bladder nor subsequent hemorrhage has ever been 
observed in my exjierience. 




Fig. 207. — Same as Fig. 204. Second application of electrocoagulation. The base of the tumor is com- 
pletely burned; its apex presents a white eschar. 



TRKA'I'.MKXT OF i'J.ADIiK): 'IT. MORS 



&.)6 



3. It is painless. Galvaiiocaiilciizalioii of hladdor tumors is re- 
mail<al)Iy ])ainloss. I^iin is Iclt only wlicii tlic cautery l)uriis tlic 
liealtliy mucous m(Mn])i-aiic. When pain is complained of, it is an ex- 
cellent indicalion llial tlic cauterization lias readied the base of tlie 
tumor. 

4. Its final results are perf(^ct. Scars examined years after cau- 
terization have always appeared smooth, soft, and re,<2,ular. 

5. Kecnrrence in situ has never been observed wlien the cauteriza- 



tion has been done thorou,2,hly 
soft, and well defined. 



The cicatiix always remains ^vliite, 




Fig. 208. — Same as Fig. 204. \'ie\v of the bladder fifteen days after the application of electrocoagulation. 
The tumor has completely disappeared; the vesical floor shows nothing but edema. 

Disadvantages of Galvanocauterization. — 1. The length of the treat- 
ment. It is out of the question to believe that a tumor of considerable 
size can be destroyed in a single sitting; repeated sessions are often 
necessary. But this applies just as well to electrocoagulation. 

2. The action is superficial. Galvanocauterization does not pene- 
ti'ate deeply into the tissues. It is a "l)lade of lire" wliicli destroys 
only that which it touches. However, this disadvantage applies 
only when we are dealing with a malignant tumor of the bladder. 
In point of fact, papillomata are superficial tumors and in the vast ma- 
jority of cases galvanocauterization is i^erfectly able to destroy them 
completely and j^revent their recurrence. In cancer of tlie bladder, 



354 CYSTOSCOPY AXD URETHROSCOPY 

llie galvanocautery is manifestly insufficient; on the other hand, the 
most enthusiastic supporters of electrocoagulation do not^m]j]oy this 
method in vesical cancer. 

Advantages of Electrocoagulation. — 1. Electrocoagulation has a 
decidedly more powerful action than the cauterj^; it penetrates more 
deeply and is much more intense. 

2. Electrocoagulation causes destruction of bladder tumors almost 
hloodlessly. During the operation not a drop of blood is seen; it seems 
to have a most perfect and certain hemostatic action. 

Disadvantages of Electrocoagulation. — 1. It requires complicated 
and highly expensive instruments. 

2. The dangers are many; e.g., perforation of the bladder has oc- 
curred in many cases. 

3. Hemorrhage is not produced at the time of operation, but eight 
or ten days thereafter, Avlien elimination of the escliar takes place; 
tliis accident has also been reported. 

4. Electrocoagulation seems to me more j^ainful than galvanocau- 
terization. Whichever method is employed, one thing is certain : The 
operation is much simj)ler with the direct cystoscope than with the 
indirect. 

Endovesical Teeataeext of Bladder Tumors by Electrolysis 

Rudolph Oppenheimer, of Frankfort,^ has i^roposed that ijaj^illo- 
mata of the bladder be treated by electrolysis. 

Operative Technic. — The positive pole connected with a wide elec- 
trode is placed on the patient's thigh. The negative pole is introduced 
into the bladder by means of a No. 6 Charriere catheter, which is easily 
admitted by any catheterizing cystoscope. The bladder is filled with 
oxycyanide of mercury solution, the cystoscope is introduced, and the 
A^esical extremity of the negative electrode is applied to the villi of 
the tumor down to its base. The current is then applied, care being 
taken not to use more than 25 to 45 milliamperes. By moving the cysto- 
scope about in different positions, the electrode will attack various 
parts of the tumor. 

During the operation numerous gas bubbles will be seen; these are 
due to the electrolysis of the vesical fluid. These air bubbles are often 
so numerous as to impair the operator's view. To correct this mishap 
the author recommends enij)tying the bladder and then refilling it. 
After the operation the patient voids fragments of the tumor of a Avhit- 
isli color for about ten days. 

Advantages. — The principal advantages which the author claims 
for this method of treatment, are the folloA\ing: 



ti;|';atmI':x'i' of p.ladkki; 'rr.Moiis .).).) 

1. II is s.-iTc. Tlic li('iii(>i-ili;i,i;(' i-- reduced lo n iiiiiiiimiiii. Ol'leii 
cN'cii llie Ncsical lliiid is pei-reclly clenr .Ml'ter lliis iiilei-\cii1 ion. As 
t'oiiip;ii'('(l willi ('led |-o('oaeul;d ion, llie dnn^ci' of peiToi'al ion is sliidd. 

'2. It is simple. Tlie leclinic is \'er\' simple and iMMpiires no coni- 
plicalcd a])|)aralus. 

.'). The Pain is Minimized. W'lieii the cntaneons clcetrode causes 
a sensation of huiaiiiii;', it is rcliex'ed hy intcrposin.L!,' wd compresses. 
Tlie \'esical electi'ode is ahsolutel \' painless. 

Disadvantages of Electrolysis. — First, tlie pi'oduction of ,uas bub- 
bles as a I'csidt of electi'olysis of tlie vesical medium. This necessitates 
em])tyiiii;' and relillin,<;' tlie bladder. Hdieii the ti-eatment is of loiiLi,- du- 
i-ation; a certain case, ti'eated by the author, recpiired nineteen a|>pli- 
catioiis to bi'in.jj,' about a cure. 

REFERENCE 

i()p])Oiilioiniov: Die intiiivosikfilo P.oliMiidluni;- dor P>lns('iipa])ill()iiir dnii-li l';i('i-tr()ly.s(', Zts-flw. 
f. rrol., 1!)];], iii, 72S. 

Endovesical Treatment oe Bladder Tumors ry Radiu^e 

This metliod of treatirient has not yet been very fully studied, but 
it -does not seem to me as thougli it were able to produce l)rilliant re- 
sults. I have liad the opportunity of using it in a ease myself, hut 
without appreeial)le I'esult. The following is a report of the case: 

A Case of Cancer of the Bladder Treated hy BadiiiniA — A man, aged sixty-five years, 
fatlier of a colleague, ^^•as referred to me by Peraire, in .fuue, IviOi). Cystoscopy revealed 
a lobulated tumor, the size of a cherry, without villi, \Yith a liard and scirrhous aspect. 
There was no bleeding. This tumor had developed on a vesical trabeculation behind and 
outside of the left vireteral orifice. Both ureteral orifices were absolutely normal. 

I suggested excision of a portion of tlie growth for microscopic examination; but the 
patient was very stout and his urethra was not very patent, so I began by passing sounds up 
to No. 60, ordering a fat reduction cure at the same time. This treatment was followed -by 
good results, and one riionth later, I was able to cystosco])0 him and extract a few fragments 
of the tumor. These fragment.s, examined by P. Anuniille, sliowed the ]irosence of a mota- 
typical pavement e[)ithelioma; the rejtoit was at'conipaiiicd l>y tliis (niinion. ''It seems to be 
of a ver_y malignant type." 

I suggestcil su|)ra])iiliic cysttitoniy, not only to be able to leniove the tunun-, luit also to 
excise ^lart of the vesical wall; but th(^ patient refnsi>d to ^^ive his consent, lie went thus 
without treatment for a year. 1 saw him again in Oclolicr, Utld; cystoscopy showed that 
the tumor had gi-own c.nisidcralily and that ils base \-.as ;;s laigc as a 1i\i' franc piece 
(silver dollar). Surrounding ils liasc wa.s a c./nsidcraldc cdeinalous area which extended to 
the prostate and completely obscured the left ui'eteral (oitice. Moreover, the general condi- 
tion was bad, the ])atient having lost fifteen pounds in two mcuiths. 

In this condition, o|u'ration being consideriMl dangerous, T ]iioposed the application 
of radium. The first ajiplication was made on October :2!i, with the assistance of Desgrez, 
whose skill in radicdogy is well known. Two tubes of radium in an elbowed catheter No. 
lil, were applied to the tumor. Sexcn a]iidical ions weri' made from October to December. 



356 CYSTOSCOPY AND URETHROSCOPY 

The duration of each treatment was about two hours, five centigrams of radium bromide 
being used. Tliis in reality contained only two centigrams of radium. «*• 

Under this treatment, it was noted that there was a distinct improvement in the gen- 
eral condition of the patient. The hematuria disappeared, the pains diminished considerably, 
but cystoscopy showed that the edema surrounding the tumor was very much increased, thus 
doubling the size of the growth. In May, 1911, another examination showed that both 
tumor and its surrounding edema were progressing materially. A few months later the 
patient died. 

It seems then that this case, studied histologically and treated 
well radiologically by a competent specialist, and also well treated 
from the cystoscopic point of view, did not benefit by the radium treat- 
ment. The only result obtained was the cessation of the hemorrhage 
and pains, but the application of the radium did not stop the continued 
development and growth of the malignant tumor. 

EEFERElSrCE 

iLuys: Bull, et mem. Soc. de chir. de Paris, 1914. 

Note. — The experience of American urologists with radium in the 
treatment of vesical cancer may be summed up in the following per- 
sonal communication from Winfield Ayres, of New York, who has had 
considerable experience with this remedy. — Editor. 

"After nearly four years of experimentation, I am forced to the 
conclusion that radium in the treatment of cancer of the bladder is not 
so effective as in treatment of neoplasms in other parts of the body. 
It has considerable action in relieving the pain, but practically none in 
stopping discharge or odor; and very little in arresting the progress of 
the disease in the majority of cases. 

''The most effective method of application in a well-developed 
cancer is by cross irradiation from the rectum to the suprapubic region, 
using massive dosage — not less than 3,000 mg. hours at a sitting. For 
a small growth, this combined with frequent, direct applications of 
the beta rays under direct vision gives the most satisfactory results. 
Intravesical applications without visual control seem to me to be too 
dangerous and too haphazard. 

"Cancer of the bladder should be irradiated before and after op- 
eration. 

' ' Thorough irradiation of a pajDilloma not only renders such . a 
tumor more easily removed by dessication, but diminishes the prob- 
ability of its return." 



'ni'KA^r.\lKXnM)K KOU'KKiX I',()l)lh:S IX TIM'; r>LAI)i)h:iJ 

l^'()f('ii;ii Ixxlics ill the hhuMcr arc <\\' 1\\() principal x'ariclics; 
iiaiiicl\\ aclual forci.^'ii Inxlics and calculi. 

ACTUAL FOREIGN BODIES 

The untoward coiiseqnciiees of foToi,t>,n IkxIIos left in tlio Madder 
are very well known. ^ Calcai'coiis sails ai'c dcjjositcd upon lliciii, lliiis 
acting as nuclei of vesical calculi. Tlie ol)jects found in tlu^ bladder arc 
varied and often most unexpected in character. 'J'lie freriiuMicy of 
fragments of bougies and catheters is easily explained; l)iit it is sur- 
prising to find hair pins, beans, pencils, pendiolders, sticks of Avax, 
needles, and even smoking pipes! It is needless to attempt to explain 
the purposes underhdng the introduction of these objects. Once the\' 
are in the bladder, what is to be done to remove them? 

First of all the presence of the foreign body must be made certain, 
either by an ordinary metallic searcher or better still, by the cysto- 
scope. Their extraction is somewhat difficult. AVlien small they can be 
extracted with Collin's ingenious extractor or with tlie lilliotiite. 
These instruments can be used onl}^ when the foreign ])odies are firm in 
consistency; but in a bladder that is irregular and trabeculated, it is 
difficult to determine whether the instrument is grasping the vesical 
wall, a vesical column, or a soft foreign body. 

The extraction of large foreign bodies is more difficult. Long and 
rigid bodies not- more than seven or eight centimeters in length gen- 
erally lie transversely in the bladder because this diameter never varies 
even when the bladder is evacuated.- When caught in this transverse 
position their extraction is impossible. It then becomes necessary to 
change their position from transverse to anlci-o])o<terior, so that they 
will follow the same roulc that llicy look wlicii iiilroduced, — lint in llic 
opposite direction. 

This can nol be done 1)lindly. AVlieii I'oi'cign bodies are to l)e i"e- 
inoved through the urethra, it is exideiil that their rapid, certain, and 
safe extraction can be assured onl\ with the eystoscope under control 
of the eye. Until recenlly, if simple means did not succeed in recov- 
ering the l»od\-, it was !iecessai-\ to resort lo sii]irapul)ic cystotomy. 



PLATE XXIV 

Fig. 1. — Tesical tumor photographed iu color several hours after cystotomy. 

Fig. 2. — Cancer of the Madder secondary to utei'ine cancer. 

Fig. 3. — Bullous edema of the iladder, following uterine cancer in a T)a- 
tient in the service of Pozzi, at Broca Hospital, opeiated on twice for 
cancer of the uterine neck; after invading the vesicovaginal wall, the 
cancer perforated the bladder. 

Fig. 4. — Purulent ejaculation from a ureteral orifice, in case of pyone- 
phrosis. 




KiK. 1. 





Fig. 2. 



Fig. 3. 




TKKAT.MK.VI' O I' l'( )I;K1( ; N IIODIKS IX TIIK lil-ADDKi; 



359 



TTowevcr safe lliis inclliod iii;i\' lie, in cxix-i-ii'iiccil liaiids, the i-ciihmIv 
seems out of ;ill pro port ion lo 1 he cliaractrr (if 1 lie 1 rouhlc 

II is clear llial dircci \i>ioii cystoscopy niiisl Ix' con-idcrcd n \al- 
iial)lc iirlp ill llic ('\li-aclioii of I'oi'cii^n l)odi.'s froiii llic Madd'-r. Willi 
this iiiclliod llic rorci,L',n lio;ly can lie seen di>1ihctly. ils cxacl position 
is (Ictcrniincd, and it can lie i^raspc*] cjTcc1i\-cl\ and ra.pidix' cxI racti'd. 

Idns is exact ly w liat liappeneil in the case of a woman, au'ed t\\i'nt\'- 
six ^■eal■s, win) nnl'ort nnatel \' lost a cellidoid liaii- pin in lier liladder 




Fig. 209. — Celluloid linii|iin, afttr having lain in tin- lil.iclilir nine days, extracted with the direct vision 
cystoscope. 'I'he ends are already enernstc<l with ealeareous salts. 

(Ki.i;'. 209). Slie re])orled lier loss to I)OS(pielle, oT .Mont Ix'liard. w iio 
referred tlie woiiian to me. On J^'ebniai'S' .'!, 19()(i, she lol<] me thai the 
''accident" liad occurred on January 25, that is, uine da\'s pre\ioiisly. 
Idle ])in \\as introduced into tlie uretlira, eonvexity tirst, and passim;' 
llirou.u'li the s))liiucter, it Tell into tlu' l)la(l<ler. Sinee tlir'n tlie patient 
eoin])laine(l of ]jain and fre<iueiit urination. 'Idiere was no liematiiria, 
but tlie urine was cloudy. 




Fig. 210. — Forceps for the extraction of foreign bodies through the direct vision cystoscope. 

I introducetl my cystoscope easily into tlie bladder and llie pin was 
seen lyiuii,- in tlie classic transvei'se ])()sition. The comexity of the ])iu 
pointed to the ri,ii,'lit of tlie ])atient. To ,u,ive the ])in an anteroposterior 
])Osition, 1 inclined mv instrument to the rii;-lit, can.^lit the loop with a 
force|)S (l^'i,!!,-. 21(1) introduced into the cystoscopic tiihe. and tuniinu- the 
pin, hroui-ht it ai'ound so thad its convexity ai)pi-oaclied the internal 
orifice of the urethra. II was then very easy to withdraw the instru- 
ment to,^-etlier with the pin. The ojieratioii was easy and ])aiiiles<. The 
])in had followed the same route coiniiii;- out as it did ,H()in,u' in, hut in 



360 CYSTOSCOPY AND Ur^ETHEOSCOPY 

an of)j)Osite direction. Tlie time required for tlie extraction did not 
exceed five minutes. 

Examined after extraction, tlie pin was found to l)e made of cel- 
laloid, and the branches measured 7^2 centimeters in length. At the 
points, a slight incrustation with calcareous salts could he -noticed. 
The patient did not suffer any inconvenience and was able to take the 
train home the same day. 

This method of extraction is extremely easy and joractical for 
smaller bodies, like the tip of a catheter, for example. To illustrate: 
A woman, aged forty-seven years, was ojDerated on, at the Charite, on 
August 28, 1905, by Auvray, in the service of Reclus. After the opera- 
tion, it was decided to tie in a Pezzer catheter, but the extremity of the 
catheter broke off, while it was being introduced, and fell into the 
bladder. It was impossible to extract it with ordinary methods. On 
September 27, I used my cystoscope and extracted it without mij dif- 
ficulty (Fig. 211). In these cases, as in any other surgical intervention. 




Fig. 211. — Fragment of a Pezzer catheter, broken off in the bladder; removed through Ivuys' direct vision 

cystoscope. (Twice the natural size.) 

the rational princijole of seeing the lesion before treating it, must be 
realized, 

I had the opj)ortunity of j^^eeing another interesting case in the 
service of Pozzi, at Broca Hospital. It was in a woman who had been 
operated on at some other hospital for vesicovaginal fistula, silk su- 
tures being used. After tlie operation, the patient complained of 
cloudy urine. With ni}^ cystoscope, I discovered a small, white, mov- 
able calculus in the bladder, and a silk thread situated on the side of 
the bladder (Plate XI, Fig. 1). 

It is interesting to note that in this case, as in almost all similar 
cases, the silk thread which united the vesicovaginal wall, was tied 
on the vaginal side. It often happens, however, that the knot becomes 
rotated toward the bladder. This is exactly what happened in this 
particular case. The small, white calculus was evidently due to the 
presence of a piece of silk thread which remained in the bladder. The 
calculus was eliminated with the urine, a little later, through normal 
urination. The silk thread was caught at the knot with a pair of for- 
ceps and gently pulled out in its entirety. 



TREATMKXT OF FOIMCIOX T.ODIKS IX TIIK BLADDER 3GI 

MniiN' iiilcrcsliiiL;- cases liavc hccii rcpoiiiMl l»y various authors. 
Tlic foliowiiift- are aiiion^' ili<' most iiiij)oi1aiil : 

Boai'i, oF Aucono, \\>^ri\ my iiisl fniiicnt siicccsvl'ully in a jtaiiicu- 
larly iiiipoi-laiil ('as(\ T]\(' Icl'l iirclci' was iiijiir<M| (liirini;- an alxioiii- 
iiial hysterectomy for lihroma. lie iiil loduccil a Xo. i) ui-clcral catheter 
into the uret( i\ so tliat its peripliei'al exti'emity eiitei-ed the hhuhhT. 
Then Jie sutured the ureter over and around the catheter. 'I'iie (j])ei-a- 
tive sequelae were regular and uueventt'ul, and tweKc days latei- Boari 
used my direct vision cystoscope and extracte(l the uretei-ai catheter 
witlioiit any difficnity.' 

Gautliier, of Lyons, extracted a ])r()ken catheter from liie l^iadder 
of a man, under local cocaine anesthesia. His report of the case fol- 
lows:'^' 

"X., aged forty years, entered the Hospital of Sainte-Foy-les-Lyon in the service of 
Gallois, on February 20, 1909. He was suffering from a syphilitic myelitis, complicated for 
a month past by an almost complete paraplegia and complete retention of urine. He had 
been catheterizing himself with a Nelaton catheter, which broke in two in the canal. The 
portion wliich remained outside was saved. On examination it consisted of a red rubl)er 
catheter No. 14, nearly 16 cm. in length. A similar catheter in perfect condition was fouml 
to be 32 cm. long; consequently the piece left in the bladder must have had a length of 
about 16 cm. The rulibcr was hard, cracked and inelastic. It had been 'baked' by time, and 
was easily broken in two. This fragility readily explained the accident. 

' ' The day following his entrance into the hospital, Gallois attempted to extract the 
catheter with Collin's tractor, but it broke; two fragments measuring two centimeters were 
recovered, however. This method was not successful. My friend Gallois then invited me 
to examine the patient. I cystoscoped him on February 28 and found a cystitis with the 
cloudy and foul urine characteristic of foreign bodies in the bladder. After a copious irriga- 
tion of the bladder I tried to remove the catheter with a lithotrite with flat jaws. Anesthesia 
was unnecessary, for the myelitis had brought about a marked analgesia of the urethra 
and bladder. 

''I was not any more fortunate than Gallois, because I did not remove any more tlian 
tluee centimeters of nonencrusted catheter, in three fragments. I did not persist, for fear 
of causing trauma in an already infected bladder. It was indeed very difficult to grasp 
the foreign body, because the sensation felt through the lithotrite was similar to that which 
is felt when the mucosa has been caught. I postponed cystoscopy for a few days to give 
the bladder a rest. In the meantime, the bladder was irrigated twice daily with a silver 
solution. 

"On April 1, I performed indirect cystoscopy. The catheter was seen immediately, 
encrusted with calcareous salts, which gave it a whitish coating and thus made it easier to 
be seen. One end was near the roof to the right, the other was to the left of the neck. 
According t(i the l;uv of accominodatioii of Guyon and Hcnviet, this olilii(ue position in the 
vertical plane gav(^ flu^ foreign body more lluui nine centiinet eis of length. 

"What was to be done? The usual instruments for extracting foreign bodies were 
fruitless, owing to the friability of tlie catheter. AVe were not encouraged to try them 
again, because the encrustation had increased the size of the object and nmde it 7nore dan- 
gerous to the integrity of the urethral mucosa. 

"We thought, naturally, of su|n-apubic cystotomy, or better still, of pcuineal section, 
which gave better drainage to such an infected bladder. But the patient was very nuicli 
depressed, suffering from sulia<utc myelitis, and a continual diarrhea produced by the injec- 



362 CYSTOSCOPY AND URETHROSCOPY 

tions of mercury biniodide. In these circumstances we were justified in hesitating before a 
general anesthesia and a bloody operation. So we decided to use the modern Luys' indirect 
rision cystoscope. In case of failure, cystotomy would be resorted to. 

'^ Having procured the necessary instruments, I cystoscoped the patient on March 8. 
It was my first attempt with this instrument in the male, and I think also, it w-as the first 
time this procedure was ever attempted in Lyons. The operative steps were as follows: 
Copious bladder irrigations with permanganate; emptying the bladder; urethral anesthesia 
with cocaine (the patient having been improved by the mercury injections, %ad recovered 
the urethrovesical sensation) ; large sounds, about 30 Charriere were passed. They tore the 
meatus and caused slight bleeding; the cystoscope was introduced easily with its elbowed 
obturator, by depressing the j)ubic region, thus relaxing the suspensory ligament of the 
penis (Guyon's method). The obturator was withdrawn, the light introduced and the urine 
aspirated with the water horn ; Trendelenburg position. 

' ' The catheter was seen heavily covered by calcareous deposits, resembling a section of 
pipe-stem covered with white clay. It was about ten centimeters in length, as was expected. 
The position was the same as that observed with indirect cystoscopy. 

''In order to disengage the catheter, its lower end which was the most accessilile, was 




Fig. 212. — View of the bladder mucosa in bullous cystitis, accompanying a foreign body in the bladder. 
(This cystitis covers two-thirds of the bladder.) (Le Fiir.) 

cut across with a sharp-blade forceps. In this way several fragments were witlidrawn 
through the urethroseopic tube. The other extremity, now movable, was also seized a't its end 
and drawn through the tube. This fragment was six centimeters long, and its caliber, in- 
cluding the encrustation, was No. 22 Charriere. 

"Cystoscopy then showed that there were still two small fragments in the bladder. 
The mucosa was very highly inflamed; small ulcerations and blackish infiltrations were seen 
here and there. A fetid odor came through the tube. Tlie patient was brought to the 
horizontal position, and the bladder liberally irrigated with permanganate. The operation 
was well tolerated and thanks to the cocaine, was painless. 

"The final results were satisfactory. Eight days later (March 15) tlie urine was less 
cloudy and foul, there was no fever and the tongue was moist. When all the recovered 
pai'ts of the catheter had been added to the part that had been saved, we obtained a length 
of 31 cm., which was just one centimeter less than the perfect catheter used for comparison." 

Another case is reported hy Ferron.® A working girl, aged sixteen 
years, entered the service of Poiisson with symptoms of severe cystitis. 
The patient attributed the affection to overwork, but further question- 
ing elicited the admission that slie had accidentally inserted a metallic 



TIIKATM KXT Ol" I'OKI'.K : X I'.OHIKS IX TIIK lU.ADDLIl 6M 

ii;nr|»iii iiilo llif lil;i(lil<'i-. I>\ the jiid <>!' dii-ccl ■,i.-i(iii cysloscojiN', l'\'r- 
I'oii i'('C()\('i('(l llic olijccl. Ill tlii> cMSc iiiiliiccl ('ys1()sc()j)y was iiii|)()S- 
sililc Ix'caiisc ol' llic <'\is1 iiii;- cxslilis. 

Slill aiiollicf \('r\- iiilci-csliiii;- case is icpoiicd hy \.i' h'iir. A 
woman had liccii sul>Ji'(d(M| to a suhloial alxloiiiiiial li\ .-1cn'cloiii>- Tor a 
lihroiiia ol' llic ulcnis. Al'h r llic o|)cralioi!, llic i)aliciit always coiii- 
plaiiicil of |)aiiis in licr ahdonicn, and llircc inonllis later, tlic suri;-coii 
w'lio had opcratcil on iici', found an inlillration ol' the xa^iiiai cul-dc- 
sac, for which he advised hot va,i;inal douche-. 'I'lie pains pei-sistcil, 
howcvci', in spile of these iii'i,i;al ions. A diagnosis of abscess of Hh; 
hi-oad li,<;aiiient was made, and a \a;-;iiial incision was jjci-foi'iiKMl in 
Febniary, 1 !)()!>. 

Ill the i'ollowin.i;' Au^'ust anolhci- sui-,i;<M>ii made an a!)<h)iiiiiial in- 
cision. Meanwhile, in A])ril, the ])atient liad he.^un to comjilain of 





Fig. 213. — Three strands of silk thread the ends of which project into the bladder. (Le Fiir.) 
Fig. 214. — Three additional strands of thread, with a knot projecting into the bladder (magnilied 
by the cystoscope). (Le Fiir.) 

pain in the bladder, and in spite of the vaginal irrigations and internal 
treatment these pains continued to grow worse. 

Le Fiir saw the patient the hrst time late in 1909. The urine was 
very cloudy and precipitated a thick layer of pus in the examining 
glass. Cystoscopy showed a very intense cystitis, which might have 
])een mistaken for a neoplasm of the ])ladder. Local treatment was in- 
stituted and the cystitis improved. 

A second cystoscopy revealed at least four or live masses ot thread 
reseml)]ing silk, attached to the pwsterioi- hladder wall, and present- 
ing a hairy appeai-ance owing to the silk libei-s. Others \\ere covei'ed 
hy a whitish mucus forming a real veil; some had tlieir ends free: iu 
others the knot of the thread could be recogni/ed. 

Le Fiir used Luys' direct cystosco2)e and he discoveivd and ex- 



364 CYSTOSCOPY AISTD TJEETHROSCOPY 

tracted a silk loop thirty centimeters in length ; he thus avoided supra- 
pubic cystotomy and improved the patient's condition considerably. 
This interesting case of the removal of a silk thread of such a length 
(Figs. 213-214) and its extraction through my cystoscope, indicate 
conclusively the great benefits that can be derived from the recent 
improvements in the technical instrumentation in c^^stoiscopy. As 
Le Flir well states it, ''direct vision cystoscopy has succeeded where 
all other exploratory procedures have failed." 

EEFEEENCES 

iLa Clinique: April 13, 1906, p. 230. 

2Henriet: Ami. d. mal. d. org. genito-urin., April, 1884. 

3Tr. Assn. frang. d'urol., 1905, p. 467. 

iBoari: Estratto degli Atti della Societa Italiana di Urologio, Congresso Eoma, April 15, 16, 
1908. 

"Gauthier: Lyon nied., April 11, 1909. 

eFerrou : De la cystoscopie a vision clirccte. Thesis,, Paul Jardon, 1912, p. 57. 

7Le Fiir: Extirpation d'une sole de O m. 30 par la cystoscopie a vision directe. Communi- 
cation to the Surgical Society of Paris, June 30, 1910, p. 618. 

sLe Fiir: Personal communication, January 25, 1914. 

TREATMENT OF VESICAL CALCULI 

Vesical calculi can be extracted through the natural channels with 
the aid of the direct vision cystoscope, only however, when they are 
not too large to pass through the urethra. This means that the cysto- 
scope is of service only Avitli small calculi; but with phosphatic calculi, 
whatever their size, direct cystoscopy stands j)reeminent. 

Treatment of Phosphatic Vesical Calculi 

These calculi are relatively frequent and occur mostly in women. 
At times they develop around a foreign body introduced accidentally 
into the bladder; at other times, the foreign body may be introduced 
during some surgical intervention; this may include a fragment of a 
catheter or bougie, or a thread of catgut fallen into the bladder dur- 
ing the treatment for vesicovaginal fistula, or a pessary which has ul- 
cerated through the vesicovaginal wall. 

Occasionally the foreign bodies are introduced accidentally; the 
long list of such objects includes hairpins, beans, peas, pencils, pen- 
holders, sticks of wax, pins, pipe-stems, etc.^ Even in a short time they 
may become encrustated by calcareous deposits; and after a certain 
period they are found covered by a turtle-shell thickness Avliich hides 
them completely. 

Phosphatic deposits may develoj) even without preexisting foreign 



TIIKATMl^XT OF VKSICAL ("AT-CriJ 365 

bodies l»y siniplc pivcipilalioii of sails in a \r\y coiicciil ra1('(l alkaline 
urine. As a imiIc IIicn' arc llic itsiiH of ii'iproix'i- aliiii('ii1ai->- liy,i:'i(Mi(»; 
or they ina\- !)•' srcondarN- lo an in1cii>c and jnolon.ucd cyslili-. \\ lien 
they develop in a previously licallliy l.lad.lcr, llicv cause an in-ilallon 
of ilie niueosa, pi'oducin.i;' a se\'ere and painful cx.-lilis. 1'liese jilios- 
))liatie deposits ol'leu adiiei'e lo the ^•esi(•al nui('o>a to -ueli a de,i;-ree that 
tlu'V can not he removed without tearin-- rra-inent.- oT the nuicosa 
aloui;' with them; tlie>- look like I'eal stalactites. 

The i)resence of these deposits can he deleruiined hy an ordinary 




Fig. 215.— View of a phosphatic calculus seen through I.uys" direct vision cystoscope. 

explorer or metallic searcher; but the surest way is to see them throii.uh 
a cystoscope. After they have been fouiul. Ihei-e are three methods of 
treatment: Lithotrity, suprapubic cystotomy and sim])le curettap 
Ihrouo-h the natural channels; but all three methods present serious dis- 
advantages. 

Crushing is insufficient. The fiagmeids ot calcareous encrustation 
which are adherent to the nnicosa, are frequently too small to be 
grasped between the jaws of the lithotrite; often they are also soft, 
which makes it very difficiUt to seize them even with the most careful 
searching of the instrument. 



366 CYSTOSCOPY AND URETHROSCOPY 

They can uiidoiibtedly be removed tliroiigli eystotoni}^; but the op- 
eration is out of all proportion to such a benign ailment, especially 
when we consider the frequent recurrences of these deposits. It would 
be absurd to advise another cystotomy for each recurrence. 

Curettage through tlie natural channels is done blindly; fragments 
are liable to remain in the bladder, thus injuring the heajjthy vesical 
mucosa. 

The real treatment is their extraction under the control of the eye, 
through the direct vision cystoscope. This method is radical, because 
it enables the operator to extract everything; it is simple, because gen- 
eral anesthesia is not required; and the patient can continue his usual 
occupation immediately after the intervention; lastly, it is absolutely 
without danger. 

The technic is simple: The cystoscope is introduced into the blad- 
der and the deposits are readily located in the form of calculi of shin- 
ing white color and various sliapes, — round, oval, pointed, stalactite. 
A forceps (Fig. 210) is introduced through the cystoscopic tube, grasps 
the fragments and withdraws them (Fig. 216). 

In certain cases there is but one calculus; this is seen when the 
deposit covers a foreign body. Sometimes they are multiple, either 
mobile or fixed to the mucosa or encysted. For the latter, the direct 
cystoscope is especially serviceable. With this instrument the entire 
surface of the mucosa can be examined systematicalh^, and the calculi 
can be removed, one after the other, with the aid of forceps and with 
the minimum injury to the vesical mucosa. 

The smallest and most adherent fragments are easily detached 
and grasped by the forceps. Sometimes a small tampon of cotton at- 
tached on a probe is sufficient to detach and extract small fragments 
which are very friable; this converts the deposits into an actual phos- 
phatic pulp. 

When the fragments are liard and small, they can be extracted 
through the tube. When they are larger than the lumen of the tube, 
they can be grasped b^^ the forceps and both tube and forceps are with- 
drawn at the same time. "WTien the calculus is too large, it may not be 
able to pass through the vesical neck. In these circumstances, because 
of its size, it is easily located by the lithotrite, which breaks it into 
small fragments; the latter are then located by the cystoscope and ex- 
tracted without difficulty. 

The postoperative steps are extremeh^ simple: Copious vesical ir- 
rigations with hot boric solution will control any possible bleeding. 
There is no necessity of leaving a catheter in tlie bladder for drain- 
age. The patient goes home, takes large quantities of warm liquid. 



TKIvM'.M i;.\"'r OK NKSICAI, CALCI'M 



367 



and iirol ropiii is prcscrilxMl ; no oilier 1 icnl inciil is ncccssai'v. Six to 
1"ii (lays lalci- cystoscojjy will he rc«|nii-('(l to vcril'y the i-csult. 

I have oflcii had tlic oppoit nnily of a|)|)lyini;- this method ol* ti-eat- 
nienl. All llie cases are icina rkalile I'or llic .-iniplicilx' ol' llie op<'rarion 
and llie excelleiil |-esnlls ol »1 a/i ikm I . TlieN' occnr ainiosi in\'a rialil \' in 
wonieii alioni fori)' years ol' a,^«', who complain (tf I'l-ecpienl urination, 
cloud}' and occasionallx hloody urine. The jiollakiuria i.- .-onietiiiies 




') Jjupret 



fig. 216. — Extraction of a pliosphatic calculus llinnigh I.iiys' direct vision cysloscoije. 

^'e^y severe, eonipellin*;' tlie patient to xoid every ten minutes, and tlie 
pain after ni'ination is very acute. With tlie ahove mentioned treat- 
ment, the p'ains disappeai' vei-y ra])idly and the vesical capacity ad- 
vances rapidly i'l'om 20 to 80 and even 150 e.c. The cure is materially 
aided l)y tlie local a])i>licatioii of a .") or 10 per cent niti-ate of silver 
solution through the cystoscope, to the points on tlie mucosa where the 
calculi were implanted. 



368 CYSTOSCOPY AINTD UEETHROSCOPY 

Two cases are particularly interesting and worth reporting. One 
was that of a woman, aged fifty-five years, with an extremely acute 
cystitis and numerous phosphatic concretions. On a previous occasion, 
in February, 1908, I extracted a great number of phosphatic masses, 
with the aid of forceps. In July, 1909, I repeated this procedure more 
thoroughly; all the calculi were extracted and the patient was com- 
pletely relieved. These calculi were examined by Carrion, and he 
found they consisted of phosphates of ammonia and magnesium. Since 
then I have applied this treatment to other cases. 

The following case is also of particular interest. 

A woman, aged thirty years, was referred to me by Gauja, on May 17, 1912. For 
three months she carried in her bladder the head of a Pezzer catheter. During a difficult 
confinement, four months previously, her perineum was torn, and sutured ; an attempt was 
then made to introduce a Pezzer catheter but its tip fell off into the bladder. The urine 
became cloudy and the microscopic examination of the centrifuged deposits showed the pres- 
ence of pus and blood. 

Cystoscopy revealed the presence of a white calculus, in the shape of a mushroom, 
vaguely resembling in outline the tip of the catheter. On May 21 this was extracted. The 
cystoscope was introduced easily and the forceps directed toward the calculus; the latter 
being smooth could not be grasped, and moreover, even when I succeeded in seizing it with 
forceps, it could not be extracted because it was too large to pass through the urethra. 
Then a lithotrite was introduced and the calculus was caught and crushed into small frag- 
ments. The cystoscope was again introduced, the fragments were extracted, and among 
them, portions of the catheter head were readily recognized. 

The operative results were uneventful. On May 24 the patient was completelj' cured; 
the urine was clear; the cystoscope did not reveal any trac« of calculi or any other abnor- 
mality of the bladder. In this particular case, one might have thought crushing alone would 
have been sufficient; but the soft fragments of the catheter could not be seized in the jaws 
of the lithotrite and they might therefore have become the nuclei of new calculi. 

Another remarkable and interesting case is that reported by 
Pulido-Martin, of ]\Iadrid.^ 

"Mrs. E. L., aged thirty years, married, mother of three healthy children; no patho- 
logic history, normal menses, no miscarriages. For a year and a half, she had noticed that 
her urine was bloody, independently of her menstruation or pregnancy; and without any ap- 
preciable cause. Becoming alarmed, she consulted a physician, who prescribed a hemostatic. 
Several days after the onset of this attack, urination became frequent with pain at the end 
of the act; these pains became continuous as the frequency increased. The urine when exam- 
ined, was purulent and alkaline, with numerous phosphatic deposits. The patient then 
consulted Angel Bueres, a distingTiished Asturian specialist, who cystoscoped her under most 
unfavorable conditions. The capacity of the bladder was not more than 60 c.c. ; the blood, 
the pain and the movements of the patient made a definite diagnosis well-nigh impossible. 
Nevertheless he was able to distinguish a white mass at the trigone, extending toward tlie 
left side. As the vesical capacity could not be increased and the pains persisted, my ex- 
cellent colleague and friend referred the patient to me. 

"She was a large, stout, pale woman, of lymphatic aspect, who seemed tired out by 
the repeated and persistent pains which she had suffered. She voided every fifteen or twenty 
minutes, day and night ; urination was very acutely painful, especially toward the end ; oc- 
casionally she had attacks of acutely painful vesical colic, when she voided large phosphatic 
concretions covered by fragments of necrotic mucosa and glary mucus. The urine was strongly 



TllEATMENT OF VESICAL CALCULI 6b\) 

alkaline and fontaincd a laifjo niiniltcr of cocci ami bacilli, from wliicli tlio tultoicle liacillus 
fould nof lie isolalcd. The travel and llie lack of 1 icatinent liad reijuced the vesical capacity 
to 40 c.c. 

"As indiri'i-l cystoscciipv was tlius inipnsMl ilc. I i iit luilnccd Liiys' iliicci cysloscope, an<l 
saw a wliitisli mass at tlic tri<;one, Jiavinj;- tlic a|i|icaiaiicr of ilic coic of a fiiiuncle. Numer- 
ous granulations of jiliospliat ic sails were spinid iiic^ulaily (ucr- 11h' mucosa, and contrasted 
NJvidly liy llicii' cdldi- with tlic rest of the iircintic tissues. TIh' mucosa was ulcerated in 
soiuc places and I he rest of IJic hhiddcr was \ciy rc(j. 

"At first 1 extiacted a few cuncictinns with Kallmann's foiceps and irrigated the 
bladder lij^ldly. Tliis treatment was repeated in three or four days. After this tli(! number 
of concretions diminisiicd and patient improved. Tiicn I instituted the following sy.stematic 
treatment: Tlie patient was put in the Luys' cystoscopic position, the cystoscope was intro- 
duced and fragments of necrotic tissue and concretions were extracted with Kollmann's 
forceps. Then the white surface was swabbed with sterile absorbent cotton on a probe, and 
the parts were then touched up with a 3 per cent silver nitrate solution on another probe, 
this being followed by a bladder irrigation. The treatment was paiidess, without local anes- 
thesia, and without hemorrhage, and the patient continued hei' acti\c social life without a 
single day's interruption. 

"The bladder condition improved at the 1)eginnin;^ slowly, then more lapidly, so tliat 
in one month the capacity had increased from 40 c.c. to 200 c.c; the pains had disappeared, 
the urine became clear and recovered its normal reaction. Cystoscopy in a fluid medium 
with indirect vision showed that the ulceration, which had been covered by necrotic masses, 
encrustations and numerous mierobic organisms, had diminished to such an extent that it 
occupied a little round space the size of a cent. This ulcer was situated above the trigone, 
toward the right side, but at some distance from the right ureteral orifice; in its center, was 
a small phosphatic deposit corresponding to a small wound situated on the anterior wall of 
the bladder; this wound was oblong in shape with its long diameter situated vertically; the 
transverse diameter was the same size as the ulcer on the posterior wall of the bladder. It 
wa,s certainly produced by friction of the encrustated ulcer of the posterior wall with the 
mucosa of the anterior surface. The posterior ulcer having })een treated locally was quickly 
cured, while the nonencrusted wound of the anterior wall, wliieh was not directly treated, 
took a long time to cicatrize. 

"The only drugs taken internally during this treatment were uraseptin and a diuretic 
infusion. When the bladder capacity had become normal, and the urine clear, a functional 
test of the separate kidneys was made ; and as I expected, I found the urine perfectly normal. 
The kidney function was slightly retarded and elimination seemed less rapid than in per- 
fectly healthy kidneys. The patient has been feeling well since then — I hear from her every 
two or three weeks — and has thifs been made lid of a rebellious and painful illness in little 
longer than a month and a half." 

Still anotlier case, also very iiileresting, is reported ))y E. Escoiiiel, 
of Arequipa, Peru, as follows:^ 

"A woman, aged forty-eight years, presented herself for consultation for urinary fre- 
quency, vesical tenesmus and cloudy urine, covering a period of several months. 

"Clinical examination revealed a painful bladder; vaginal examination, negative. Tlie 
patient voided ten to fourteen times during the twenty-four hours, the total quantity never 
exceeding 1600 c.c. Vesical capacity was 200 c.c, and when that limit was reached she had 
an imperious and almost painful desire to void. Microscopic examination of the urinary 
sediment showed many leucocytes, bladder cells, a few urethral and ureteral epithelial cells, 
and numerous small cocci. Earthy phosphates were also present. 

"Cystoscopy with Luys' instrument, the use of which I had learned from its inventor 
himself, revealed a chronic catarrhal cystitis and a small soft, phosphatic calculus, firmly 
■ fixed and encrustated at the bladder fundus and partly envcloiicil by the nuicosa. 



370 CYSTOSCOPY AXD rRETHROSCOPY 

''The calculus was grasp.ed and broken up with an endovesical forceps. I have the 
fragments in my surgical collection. I curetted the mucosa, completely extirpating all the 
embedded fragments with a small curette that could easily pass through the cystoscopic tube. 
The small vesical wound was swabbed with 3 per cent silver nitrate solution, the cystoscope 
withdrawn and the bladder irrigated with a solution of protargol 1:1000, using a large 
catheter. The irrigations of the bladder were continued for several days, with oxycyanide 
of mercury solution, 1:4000; urotropin internally. 

' ' The after effects were uneventful. The old cystitis improved very ^pitlly. Cystos- 
copy was repeated twenty days later, and the ulceration caused by the calculus was cicatrized. 
The rest of the mucosa was pale and in fine condition. Microscopic examination of the 
urine showed no cocci nor leucocytes. The patient was then referred to the hydromineral 
station at Jesus, near Arequipa, the waters of which are specific for urinary calculi. The 
patient returned completely cured. " 

Two other cases, reported by Ferron,* also sliow the facility with 
which fragments of calculi can be extracted through the direct vision 
cystoscope. In one case a woman, aged fifty-seven years, in the service 
of Pousson, was operated upon for a vesical calculus by lithotrity. The 
operation was done without undue incident, but a few days later, she 
developed a rise in temperature, the bladder became painful and could 
not tolerate the irrigations. 

Under direct vision c^^stoscopy, four fragments of calculus and a 
large quantity of inspissated jdus were removed. On the same day the 
temperature droj)ped to normal and remained so, and the symptoms 
of cystitis rapidly disappeared. 

The second case is that of a man sixty-eight years old, with nu- 
merous calculi of relatively small size. Ferron, using the direct cysto- 
scope, removed twenty-four calculi in two or three sittings; the two 
last calculi being somewhat larger, necessitated meatotomy. 

It can thus be seen how serviceable this method really is, inasmuch 
as it made iDOSsible the removal of a calculus of V^-2 cm. 

Conclusion: Considering the results mentioned in the jDreceding 
reports, it may be concluded that direct vision cystoscopy is distinctly 
indicated in all cases of foreign bodies in the bladder without excep- 
tion, both in the male, as well as in the female. This is the only method 
which makes the extraction of foreign bodies possible under the most 
favorable conditions and in the shortest time. 

The size of the foreign body is not a contraindication against this 
method, because, as has already been shown, a hairpin, 7^2 cm. long, 
can be removed by this method. In the case of a calculus, preliminary 
crushing will enable us to remove all the fragments without overlook- 
ing any. Finally, this method conforms with that principle of all ra- 
tional surgery which demands that the lesion shall be seen l)oth before 
and during the treatment. 



TltKAT-MKNT OK ('\S'|-1TIS 1371 



TiKrKItKXCKS 
iLuys: MeilKiilc ii:irli(iii(' d 'cxI imt iuii ilcs curiis ol iiiii^icrs ilc l;i vcssic, Lii f 'liiii(|iic, A|'ril 

1.1. lonn. 

■ I'liliild M.-iiliii: I'n ciis (If cystitc (■liriiiiii|ii(' iiicnistiiiilc ^^in'-iic |i!ir I ':iii|ilic;i( ion dircctc ilc 
1 ii|]ii|ii('s ;iu iiKiyi'ii ilu cyst i)sr(]|ic i\f I.iiys, llitli Scssiuii of the Frciicli rr<il(i;^ii-!il Assn., 
Paris, ()i-1(ilicr. llMl', p. 7(i;;. 

.■^Escdiiicl : La ('lini.|u.', October ."I, I'M:!, No. 40, p. O.'U. 

•iFcnoii : 'i"liisis of .lanlon, p. ()5 ; ulso Calculs vfvsiciiux ot CyHtoscopic h vision ilirccif, Jour. 

(1 'iii-oi., r.»i:;, iii. p. :;i!». 



TREATMENT OF CYSTITIS 

At ilio present da}, it is generally admitted lliat iiiflaiiniiation of 
the N'csical iimcosa in tlic vast iiia.jority of instances, is tlie result of an 
iiillaiiiiiiatioii of sonic ad.jacciit ori;aii, and tliat the so-ealled idio])atliic 
cystitis does not exist as a real entity. Xcvcrtiidcss, tlic painl'nl >\nip- 
tonis of cystitis constitute a ])at]i()lo*;ic enscnihlc wliidi is iin])ortant 
enough to demand an appropriate local therapy. This inqjortant fact 
that cystitis is a secondary lesion, must control our general direction 
of tlie treatment of cystitis. 

It is therefore essential to know the causes which underlie the 
cystitis, before we can apply the treatment. There are three j^rinciijal 
causes: Eenal, inflammation of adjacent organs and forei<;n bodies. 

1. Cases of Renal Orig^.— This is the most frequent cause of 
cystitis. In these cases treatment applied to the bladder will never 
be able to connteract the action of the urine which is continually com- 
ing down from the diseased kidney, loaded witli microbes and pus, thus 
irritating the bladder and ])roducing the intlammation. 

2. Inflammation of Adjacent Organs. — In the male, intiammation 
of the prostate and seminal vesicles is one of the most frequent causes 
of cystitis. In the female, gonorrheal and tuberculous intlannnation of 
the nterns, tubes, and adnexa, is one of the most common causes. 

But the organs in the immediate vicinity of the bladder are not the 
only canses of cystitis. Pelvic abscess may attack the bladder: a 
pnrulent collection in the appendix may perforate the l)ladder ; a can- 
cel- of the rectum or of the vagina or a cold abscc^ss of the vert(0)ral 
column may rupture into the bladder. 

8. Foreign Bodies. — h'oi-eign bodies remaining in the bladdci' for 
some length of time, w ill ])roduce inllannnation, whether they he endo- 
genous, like calculi, or exogenous, of infinite variety (see page 357). 

The diagnosis of cystitis can really be made oidy through cystos- 
c()])y, much beiler lliaii through the thi'ec cardinal syniptums of c\-('ry 
classic textbook, namely, pain, tVe(|uency, and ])yuria. 



372 CYSTOSCOPY AND URETHROSCOPY 

In cystitis, indirect cystoscopy is markedly inferior to tlie direct 
method. First, because the affected bladder will not tolerate a proper 
distention by the flnid, owing to the painful contraction of the walls 
and the hemorrhage which it produces. A bladder Avitli cystitis is 
very sensitive to the slightest contact; indirect cystoscopy is therefore 
uncomfortable both for the patient and the surgeon. 

Another disadvantage is found in the fact, already mentioned 
above, that it is impossible to apply apj)ropriate local treatment at 
will, even though the lesions have been distinctly isolated. 

Direct vision cystoscopy eliminates all these disadvantages and 
gives the best results. In the first jilace, there is no minimal vesical 
capacity for my direct vision cystoscope; the bladder dilates normally, 
without being forced, and consequently without pain. Usually pain 
is felt only when the tube enters tlie bladder, owing to the inflammation 
of the vesical neck. This little disadvantage can be easily overcome by 
the employment of local stovaine anesthesia. But once the instrument 
has entered the bladder, the best results can be obtained. 

It goes without saying, that in cystitis as in urethritis, it is highly 
inadvisable to apply local treatment to the mucosa as long as it is acute- 
ly inflamed; when this condition has receded through the use of proper 
medication, the direct vision cystoscope can be used with telling re- 
sults. In these circumstances, cystoscopy shows tliat the mucosa is 
inflamed in certain spots, while the rest of the bladder is normal and 
devoid of any lesion; red and bloody patches of severe cystitis can be 
seen adjoining the pinkish white health}^ mucosa. It may thus be seen 
how irrational it is to apply active medicinal substances to the healthy 
mucosa as well as to the diseased parts simultaneously. The rational 
method is to treat the diseased areas vigorously and actively, omitting 
the healthy portions. This can be accomplislied by the use of the di- 
rect vision cystoscope, through which it is possible to treat' the dis- 
eased portions by the cautery or the silver stick, while the healthy 
parts are not interfered with at all. 

Operative Technic in the Treatment of Localized Cystitis 

The operative technic of the treatment of cystitis with the direct 
vision cystoscope is the same as that used in direct vision cystoscopy 
in general. The entire mucosa having been examined and the lesions 
localized, the end of the tube is brought directly in contact with them. 
The mucosa is then cleaned with a swab of sterile cotton, in order to 
obtain a more intense action of the drug to be employed. The mucosa 
Jiaving thus been dried, concentrated solutions appropriate to each par- 
ticular case, are then used. 



TIM:AT.M KXT OK ('-/S'l'ITIS 6(6 

Til ^oiion'lic.'il cNstilis xciy iiiai'ki'd I'csults ai'c ()l)laiiie(l by the use 
of local ap|)li('alioiis of 7) lo 10 j)(>|- ceiil siKci- iiid'ale sohilioii; occa- 
sioiiall>' the pure siKcr slick iiia>' lie iisc(| with .^ucccss. In tlif roi'iii of 
clii-oiiic cystitis wliicli is riiMnicnl l\- ()1is('I\(mI in woincii, due lo a liii;li 
(l('_Ui-('(' of POiU'Oiitration of llic iiiiiic, the lesions are locaiiziMl; tiiey ai'e 
well shown in Phite XII, Fii;-. .'!. In these cases, the silver applied lo- 
call\' to the alTeclcd parts, ,i;-i\('s alisolutely reniai'kahle i-esulls. 

I iinnnieialile cases liaxc lieen repor1e(| with the most con('ln>i\(' re- 
sults. When a cxstitis has had a lon^' duration, or when the extremely 
thickened mucosa presents indurated ai'eas at certain ])oints of its sur- 
face, it ma\' he mistaken I'oi' a neoplastic piolileration. In these con- 
ditions, 10, 20, or e\-eii .^O pei" ceid soluli(Mis of resoi-cin may ])e used 
witii <;• ratifying;' results. It ^oes without sayini;', of coui-se, that much 
care must he taken in the use of such couceidrated a])])licatioHs, lest 
they s])i'ead to the suri'oundin,'^- liealths' tissuc^s. To j)revent this pos- 
sible spreadin*;' of the solution, it is safe)' to di-\' the mucosa aftei' the 
application of the caustic has l)een made. 



Sfflte 




Fig. 217. — Silver nitrate stick for endovesical cauterization. 

In some instances, the galvanocautery may be used, Imt its appli- 
cation must be extremely superficial, and made very gently. I nder 
these precautions they are both painless and effective. 

Eeports of cases of cystitis cured witli the direct vision cystoscope 
are innumerable; only a few will be mentioned here. 

In one instance a cystitis developed subsequent to the ojx'iiing of 
an abscess near by; it was Avonderfully improved l)y the application of 
silver nitrate to the affected surface. Only a few ai^plications were 
I'ecpiired to produce this excellent result. 

In a second case of cystitis, due to perforation into the bladder of 
an abscess secondary to Pott's disease, local treatment with the cysto- 
scope gave a most happy result. 

In tuberculous cystitis whicli is usually so rebellious to treatment. 
direct view cystosco])y can be of luirticulai \alue. In the vast majority 
of cases, this tuberculous cystitis is secondary to a tuberculous inllam- 
mation in the corres])oiidiiig kidney; the real tretdment of unilateral 



374 CYSTOSCOPY AXD URETHEOSCOPY 

renal pyoneplirosis is of course, nephrectomy. Nevertheless, very 
painful symptoms of cystitis jDersist as a rule, long after this operation, 
and in such cases direct vision cystoscopy gives most splendid results. 

Ax)plications of tincture of iodine, silver nitrate, concentrated so- 
lutions of lactic acid, or the actual cautery, are usually painless and 
liighly effex?tive. ^^ 

Ferron Ims published' reports of two interesting cases, on this sub- 
ject. 

Case 43. — ^A woman, aged twenty-six years, had a right nephrectomy performed on 
July 17, 1909. After the operation, although her physical condition was good, she still 
complained of resical sj-mptoms. Local treatment with the direct cystoscope gave m-ost 
excellent results in a short time. 

Case 41. — This case is very conclusive. A woman, aged thirty-three years, was nephrec- 
tomized for a left renal tuberculosis, on August 2, 1910. After the operation, she still had 
symptoms of tuberculous cystitis; tliis condition was treated according to Luys' method. 
The improvement was rapid and a gniinea-pig inoculation in 1910 was negative. Before the 
treatment, the patient had voided every five minutes by day, and had incontinence by night; 
after treatment diurnal micturition became normal, and there was no call to void at night. Her 
vesical complaint was perfectly cured. 

Paul Jardon has stated" that direct vision cystoscoj)}-- is indicated 
in all cases of cystitis; it assures a thorough examination of the blad- 
der and makes possible a rational treatment of the lesions. 

KEFEREI^rCES 

iFerron: Du fouctionnement du rein restant ajjres nephrectomic, Bordeaux, 1910. 
2Jardon: Be la cystoscopie a vision directe, Bordeaux, 1912, pp. 44 and 45. 



INSTRUMENTAL EXPLORATION OF THE INFERIOR 
EXTREMITY OF THE URETER 

Thanks to the cystoscope, the inferior end of the ureter can be 
examined in the same manner as Ave examine the urethra. For this 
purpose Kelly^ used a slightly curved blunt probe which he called a 
"searcher." Jeanbrau utilizes a metallic explorer with a flexible 
shaft for extraperitoneal ureterolithotomy. Ferron^ also uses metallic 
instruments consisting of a flexible shaft ending in a No. 7 or 8 bulb, 
and similar to Guy on 's ureteral explorers. Pasteau has constructed 
ureteral explorers of rubber, similar to Guyon's instruments. 

The caliber and condition of the ureter can be ascertained with 
any of these instruments. The technic is the same as that in urethral 
exploration. When the instrument is arrested at a given point, it is an 
indication of the presence of an obliteration, a Ivink, a tight stricture, 
or a calculus. When, on the other hand, a fine instrument passes be- 



EXPLORVTfON' OF THE UPiETEH O < 

yoiul an obstriu-tioii l)ul ])roseiits a sudden i-elaxalion and free move- 
ment on being Avitlidrawn, a .stricture may be taken for granted. 

This method of examination is also occasionally employed for the 
extraction of a calculus or a foreign body from the ureter. I have tried 
dilatation of the ureter in a woman with a ureteral calculus, in Pozzi's 
service. I introduced a bougie into the ureteral orilice and left it in 
place for twentj^-four hours, to bring about dilatation. The attempt 
was unsuccessful, because the calculus was embedded in and adherent 
to the mucosa, and could not be moved. It was subsequently ex- 
tracted through a subperitoneal laparotomy. 

Other foreign bodies can likewise be extracted froin the ureter ])y 
means of a fine forceps. Thus, I was once called u])Oii to extract a ure- 
teral catheter from the bladder, in one of the largest surgical services 
in Paris. During the course of an exploratory laparotomy, conti-ary 
to all expectation, a large calculus was discovered in the right ureter. 
The calculus was removed, the ureteral wall sutured and a catheter 
introduced into the lower end of the ureter for urinary drainage. The 
catheter was deemed long enough to extend into the interior of the 
bladder. 

I was therefore called upon, several days after the opei-ation, to 
remove the catheter, which was thought to be in the bladder. To my 
surprise, I found the bladder absolutely empty, without any trace of 
a ureteral catheter. But the ureteral orifice -was extremely puffy. A 
small forceps w^as introduced into the ureter, but nothing w^as felt. It 
was then believed that the catheter had remained in the ureter and 
had not descended into the bladder. Another operation was there- 
fore subsequently performed; the lower extremity of the kidney was 
exposed and the pelvis incised. The catheter w^as found at the upper 
end of the ureter. It was immediately removed, and the patient made 
an uneventful and perfect recovery. 

Apart from the exxDloration of the ureter per se, another indica- 
tion for ureteral catheterization, of the greatest importance, is the in- 
sertion of a catheter into the ureter, before operating upon the ureter 
or upon one of the adjacent organs, so as to be able to identify and 
protect the ureter. 

Endoscopic uretero -vesical 7neatotomy for the removal of a cal- 
culus from the ureter in a female, was reported by Gauthier, of Lyons,' 
as follows : 

"C, aged tliirty- seven years, entered the Hotel-Dieu Hospital of Lyons, on April 20, 
1912, in the service of my teacher and friend. Tixier, for chronic and persistent nephritic 
colic. No hereditary urinary history; father died of pulmonary tuberculosis. 

"Personal history: It seems that about ten years ago, she suffered from a gastric 



376 CYSTOSCOPY AjStd urethroscopy 

ulcer, for about three or four years. This was sul;sequently cured. For the past three years, 
she has complahied of pains in the left lumbar and right iliac regions. The lumbar pains 
are the more severe ; these are real attacks of renal colic, occasionally lasting twelve hours 
and coming on almost at weeldy intervals during recent months. The pains in the right 
side are continuous, with exacerbations from time to time. During these crises they radiate 
toward the corresponding thigh, which appears as if paralyzed for the time being. During 
these iliolumbar attacks, she also complains of vesical symptoms ; i. e., increased frequency 
and cystalgia. When the crises have subsided, the bladder is quite normal. 

' ' She never passed any calculi or gravel. At the beginning of her illness she had a 
few attacks of hematuria, but it is difficult to determine their character. Tire patient has 
lost much flesh and strength; her a^Dpetite is poor. 

"Examination: General condition fair; no fever; lungs and heart normal. The urine 
is not clear, and coirtains leucocytes, urinary eisithelium, and a few red blood cells. A large 
albumin ring is out of all proportion to the xjyuria. Palpation of the kidneys and ureters, 
reveals the following painful areas: On the right side, costolumbar and upi)er middle ure- 
teral ; on the left side, the costolumbar and middle ureteral. The inferior pole of the right 
kidney is palpable and sensitive; the left kidney can not be felt. 

' ' Vaginal examination reveals a metritis of the neck and a moderate vesical prolapse. 
A hard mass is felt distinctly in the left lateral vaginal cul-de-sac. This mass is about the 
size of a small kidney bean, and is continued upward and outward by a thick elastic and 
resistant cord, haviirg the caliber of a No. IS rubber catheter. 

"It is evident that this cord is the ureter and that the hard mass is a calculus embedded 
in tins canal. The diagnosis seems to be quite certain according to the examination. Tliis 
is a case of double renoureteral lithiasis. Eadiography of the entire urinary tract shows a 
localized lithiasis of tha right kidney and left ureter. There are no stones in the left kidney 
or the right ureter. In the right kidney, a large shadow is clearly seen, the size of an ordi- 
nary plum. Three distinct shadows are seen in the left ureter. The lowest corresponds 
exactly in size with the kidney bean f ourrd on vaginal examination ; the others are about 
half its size. Cystoscopy showed a normal bladder. The left ureteral orifice, though slightly 
red, is not larger than the right. The ureters were not catheterized. 

"We decided to attack the right kidney first, rejecting external ureterotomy at once. 
Operation, May 6, 1912 (Tixier). The calculus is distinctly felt in the renal pelvis, and is 
removed by pyelotomy, notwithstanding its large size. It weighs 16 gms., and is uratic 
in appearance. 

"The results of the operation are excellent; no fever, maximum temperature being 
100.6° F. Urinary escape ceased in eight days, and total closure of the wound in fifteen days. 

"On the eleventh day, violent nephritic colic, with temperature of 104° F. aird oliguria. 
For four days the temperature varied between 102.2° and 10-t°. Sharp lumboiliac pains, 
scanty urine; then sudden defervescence and disappearance of the pains and increase in the 
ciuantity of urine passed. 

"After 48 hours of normal temperature, left ureteral catheterization (on May 22), in 
order to ascertain the exact position of the lower ureteral stone. We attempted to remove 
it through the natural channels. An obstacle is encountered about 4 cm. from the uretero- 
vesical orifice. A No. 13 catheter is introduced to a distance of 15 cm. About 250 e.c. of 
cloudy renal urine are thus evacuated. The urine contains a few leucocytes, many crystals 
and a little albumin. The high fever coincident with the attack of left renal colic can not 
be explained by the retention of the septic urine. The urine retained in the kidney can not 
be considered purulent because it contained but a few leucocytes. 

"On May 23, two days after the catheterization, instead of the improvement we ex- 
pected, the colic aird temperature (102.2° F.) reappear. Radical operation is decided upon. 
Before the external ureterotomy, we will attempt removal of the large lower stone through the 
natural channels. Transverse splitting of the orifice and the ureter will be tried endo- 
scopically. Tliis will be follow^ed by combined traction through the bladder and rectum, to 
bring the calculus into the bladder. 



KXI'I.OKATIOX Ol' 'I'lIK lltliTKJ; .] i ( 

''AFjiy 1^."), ("iiiliisc()|iic operation ((Jaiitliicr). F'ationt is phicpil in the inclined posi- 
tion Mini ctiici i/.cil. 'I'll.' uictiira is dilated and Luys' evstosfopo. nieasurintr 14 mm. in 
diameter is introduced, 'llw loft ureteral orifice is seen readilv. This is catheterizod with 
a rulilier conductor, No. 4 Charriere and Maisonneuve, 5 cm. in len^^th, screweil upon a 
straight tmmeled metallic Maisonneuve conductor. Tiie entire ruldier conductor (carrier) 
is inserted into the mctci-, between the ureteral wall and the stone. Alioiit .'I cm. of the 
metallic conductor is passed into the nii'teriil orifice. .\ Maisonneuve No. 2 knife is 1 hr-n 
en<^a>^ed in tin' -roo\c of ihr conductor and advanced toward the meatus. The orifice is 
then split umler the control of the eye; nothing;- lias been done in the dark, thanks to the 
larjje lumen of tiie cysto.scopic tiilie. The Made is advaii<-ed until its summit ilisajipears 
in the vesical mucosa. I[emoi'rlia;;e is moileiale. 

".Ml the instiiinients are now rem<i\-ed from the lilaihler. The urethra is dihilerl up 
to IS French. The left index finoer is introduc<'d into the bladder, llie iij;ht into the redtini. 
Both hiijrers fee! the stone distinctly {jiaspinti it and (b-awin<;- it into the bladder, whence 
it is extracted. The operation is OJided ; it has lasted about tifteen minutes. 'Hie calculus, 
has the shape of a date seed, aiid wei<;hs 0.80 om. 

"On the followiii- day, a second stone, wei;:hin- 0.35 uni. is spontaneously eliminated. 
On the third day, a third stone is passed, weighing O.l.j gm. Thus the patient is made rid of 
1h(^ threc^ stones reveah>d by the x-ray. 

"IVrmauent apyrexia is attained on the eighth day. The quantity of urine increased 
enormously after the relief of the left kidney. She passed from 200 to 400 c.c. on Mav 29, 
and more than two liters during an entire week. 

■'On June 8, albuminuria disappeared. On tlie same day it was found that the length 
of the left ureteral orifiec is five to six mm. Xo definite trace of the incision can be seen. 
The bladder is normal, not inflamed. A catheter Xo. 14, penetrates the left ureter easily, 
for about 25 cm. There is no pyelitic residuum. The pelvic capacity is 45 c.c. The patient 
left tlie hospital in perfect condition. 

"On August 24 she was seen again. She complained of left lumliar pain principally 
at night. There is a certain relationship between these pains and her digestion. The pains 
are diminished perceptibly on a restricted diet. She al.so has acid eructations and epigastric 
inflation after meals and frequent headaches. 

"Tlie general condition is improved; she has gained thirteen pounds since leaving the 
hospital. The urine is clear; no ;illmmiii. Palpation of the kidneys and ureters is not pain- 
ful. Left catheterization is negative. Appropriate diet is prescribed for the dyspeptic 
trouble. 

" Sei)temljer 27, the jiatient writes that her left lumber pains have nearly disappeared 
under the regulation of diet. ' ' 

Conclusions. — Ureteral stricture often obstructs tlie passage of a 
ureteral stone. AVhen the calculus can be moved, ureterotomy is indi- 
cated. Tliis is easily done in women tbrou.iili the natni-al channel.^, 
using Maisonneuve 's straight urethrotome, introduced through Luys' 
14 nmi. cystoscope. Tlie operation must ])e done cautiously, avoiding 
the periureteial venous plexus; it is also impei-ative to avoid cutting 
the bladder proper. If tliis inctliod fails, external iirelerotoniy can al- 
ways be I'esorted to. 

Ferron also has reported an interesting case, which shows the con- 
siderable value of dilatation of the inferior extremity of the ureter for 
tlie establisliiiiciii oi' tlic IVcc ui-in;ir_\- How IVom llic k-iijncy.' 

"A girl aged eighteen years, suffering from gonorrheal cystitis, cimiplained of pain 



378 CYSTOSCOPY AXD TEETHEOSCOPY 

in the lumbar region. Bimanual examination revealed pain on the right side, although the 
kidney was not perceptible. The cystitis was treated locally through Luys" cystoseope and 
improved I'apidly. 

"Examination of the ureteral orifices then became possible. The left orifice was found 
noi-mal, but the right orifice was the size of a pin point, and too small to permit the en- 
trance of the smallest catheter. The ureteral ejaculation on this side occurred in the form 
of a filiform-sized jet. 

' • The extremity of the cystoscopic tube in contact with the neck, we wei^ enalded to 
demonstrate to the gathered students of the service, that a filiform jet of urine, emerging 
from this orifice, shot across the cystoscopic field and struck the anterior wall of the blad- 
der, although the viscus was distended with air. This orifice was dilated with filiform 
bougies, in a few sittings. Catheterization became easy, and the two hour test revealed a 
normal kidney. The patient was kept under regular obseiwation but never complained again. 
We believe her former pains were due to the ureteral stricture. ' ' 

Bransford Lewis^ also favors the extraction of ureteral ealciili 
tlirongli tlie natural channels. He either dilates the ureteral orifice or 
he grasps the calculus with a crocodile forceps fitted upon a flexible 
liandle. He introduces it into the ureter, advances it up to the calcu- 
lus, grasps it and gently Y\ut]idraAvs it. He tlius removes ureteral cal- 
culi even in the male. 

[The editor^ reported a case of calculus impacted in the ureteral 
orifice in a young man. Indirect cystoscopy shoAved a jagged point of 
the stone jDrojecting beyond the ureteral orifice into llie bladder, but 
held tightly. H was seized by an oi^erating forceps, and though the 
projecting tip broke, the remainder of the calculus was grasped Avithin 
tlie lumen of the ureter, at the same sitting, and witlidi'aAvn from the 
bladder. There has been no recurrence since then. — Editor.] 

EEFEEEXCES 

iKelly: Am. Jour. Obst., 1895, p. 12. 

2Ferron: Jour. d'uroL, December, 1912. 

sG-authier: Assn. franc, d'urol., 191o, p. Q-iiQ. 

•iFerron: Jour, d'urol., 1913, iii, 65. 

sLewis: Xew York Med. Jour., Xov. 15. 1912. p. 1002. 

eWolbarst: Urol, and Cut. Eev.. .January, 1915, xix, Xo. 1. 

VESICAL BIOPSY 

Histologic examination of fresh specimens of vesical tuiiior-^ is of 
great imiDortance in making a diagnosis; this desideratum is realized 
in a very simple and perfect manner Avith my direct Ausion cystoseope. 

In tAvo cases, this procedure lias given me signal results. A 
Avoman, aged sixty-tAvo years, Avhom I nephreetomized for left renal 
tuberculosis tAvo years preA'iously, came to me Avith hematuria. Cysto- 
scopic examination of the bladder shoAved a number of budding masses. 



VESICAL, BIOPSY 379 

Considering' the age ol.' the ])atient, th(\<e bodies mi^^ld have Ijeen con- 
sidered epithelioniatons in cliaraetei-. 

Histologic exainiiialioii of fi'ag'iiieiits reiiiove(l thi-()UL;'li tlie cysto- 
scope, revealed only sini])le intiannnatoi-y nodules, due to a concen- 
trated tuberculous cystitis. Local apijli^^dioiis of a concentrated solu- 
tion of lactic acid were followed by excelh'iit and rajjid results. 

Anothei- cas(\ a man, aged sixty-five years, presented a small tu- 
mor on the left lateral wall of the Idadder Ix'hind the ureteral orifice. 
Microscopic examination of a fragment oL' tissue revealed a vesical 
epithelioma. The history of this case is reported in detail in connec- 
tion with the application of radium in vesical tumors (page 355). 

Vesical biopsy should be resorted to as often as possible, for the 
establishment of a correct diagnosis; its splendid results can ])e l)est 
appreciated by anyone using the direct vision cystoscope for this 
purpose. 



INDEX 



A 

Al^scess, jieriurctlual, 1)8 
Adrenalin, in uiPthroscopy. SI 
Alypin, in uietliral spasm, 190 

in urethroscopy. 77 
Anatomic considerations of )>la(l(l(M-, 
Anomalies of bladder. 206 
Appendicitis, cystoscopy in, 144 
Aspiration of urine, 223 

B 

Binocular vision, 178 
Biopsy, vesical, 378 
Bladder : 

anatomic considerations^ 147 

anomalies, 206 

biopsy, 378 

calculus, 164, 284, 364 

cancer, 163. 208, 300, 355 

capacity for cystoscopy, 190 

deformity in pregnancy, 248 

diverticulum, 206 

fistula, 336 

foreign bodies, 357 

herpes, 228 

in indirect cystoscojDy, 198 

leucoplakia, 204, 240 

neck, 176, 202, 310 

abscess of, 310 

polypi on, 270 
normal mucosa, 149, 198 
papilloma, 160, 163, 176, 202, 338 
pathologic mucosa, 199 
perforation, 142, 176, 236 
lahotography, 179 
silk thread in, 188 
syphilis of, 188 
trabeculated, 214 
tumors, 205, 329, 358 

differential diagnosis, 206 

electrocoagulation in, 347 

electrolysis in, 354 

galvanocautery in, 330 

radium in, 355 

snare in, 342 

treatment of, 329 
urine, aspiration of, 223 
varix, 164, 207 
Bullous edema, 204, 209, 322, 358 

C 

Calculus, ureteral, 307, 311 
vesical, 164, 284, 364 



147 



Cancel', uterine, 211 

vesical, 163, 208, 300, 364 
Capacity of Ijladder, 190 

of renal pelvis, 210 
Casts, vesicular, 123 
Cathetci', ureteral, 262 
radiography of, 326 
infection by, 293 

wax-tipped, 308 
Catheterization : 

of ejaculatojy ducts, 115 

ureteral, 210,' 254 
a demeure, 324 
dangers of, 291 
errors in, 298 
in childien, 306 
indications for, 307 
Kelly's method, 267 
Luys' method, 269 
Central figure in hard infiltration, 91 

in soft infiltration, 90 

in urethroscopy, 82 
Children, cystoscopy in, 193 
Colic, renal, 312 

Contraindications to urethroscojiy, 81 
Cystic urethral glands, 97 
Cystitis : 

acute, 199 

chronic, 200 

follicular, 203 

gonorrheal, 203 

granular, 203 

parenchymatous, 201 

treatment of, 371 

tuberculous, 203 

villous, 201 
Cystoscopes (types) : 

Albarran, 256 

Baer, 180, 261 

Bierhoff, 259 

Brenner, 254 

Brown, 255 

Casper, 256 

Cullen, 60 

Delbet, 61 

Fenwiek, 175 

Frank, 260 

Freudenberg, 260 

Garceau, 58 

Guterbock, 175 

Hogge, 59 

Israel, 259 

Janet, 61 

Kelly, 57 

Kollmann, 180 

Luys, 61, 224, 333 



581 



382 



Il^DEX 



Cystoscopes — Cont 'd. 
Nitze, 168, 255 
Pawlick, 58 
Rocher, 175 
ScMagiutweit, 177 
Wossidlo, 260 
Cystoscopy, 139 
bladder in, 147 
bladder capacity for, 190 
dangers of, 165 
direct vision, 56, 218, 245 

advantages of, 234 

during pregnancy, 248 

objections to, 242 
errors in, 162 
history of, 54 
in appendicitis, 144 
in bladder cancer, 208 
in bladder tumors, 205, 241 
in children, 193 
in cystitis, 199, 228, 240 
in diverticulum, 193, 206 
in female, 193 

in perforation of bladder, 142 
in pregnancy, 241, 248 
in prostatic hypertrophy, 141 
in utei'ine cancer, 207, 211 
photographic, 179 
prismatic, 168 
indirect vision, 168 

advantages of, 194 

diflficulties of, ]89 

disadvantages of, 194 

technic of, 181 

technie of, ISl 
Cystotomy, suprapubic, 329 



D 



Dangers of cystoscopy, 165 
Differential diagnosis of bladder tumors, 206 
Difficulties of indirect cystoscopy, 189 
Direct vision cystoscopy, 56, 218, 245 

advantages of, 234 

objections to, 242 
Disadvantages of indirect cystoscopy, 194 
Diveiticulum of bladder, 206 



E 



Edema, bullous, 204, 209, 322, 358 
Ejaculation, ureteral, 158, 176 
Ejaculatory ducts, 101, 104 

catheterization of, 115 

stricture of, 128 
Electrocoagulation, of bladder tumors, 347 
Electrolysis, in bladder tumors, 354 
Endoscoi^y (see Urethroscopy) 

history of, 25 
Endourethral treatment of prostatic liyper- 

trophy, 135 
Endovesical treatment of bladder tumors, 330 
Errors in cystoscopy, 162 

in ureteral catheterization, 298 



Female, cystoscopy in the, 193 
Female urethra, 112 

urethroscopy in the, 110 
Fistula : 

urethrovesicovaginal, 214, 236 

vaginal, 236 

vesical, 336 

vesicovaginal, 237 
Follicular prostatitis, 101 **■ 

urethritis, 96 
Foreign bodies in bladder, 357 

G 

Galvanocauterization in bladder tumors, 330 
Glands, Littre's, 84, 95, 132, 146 
cystic, 97 

H 

Hard infiltration, 88, 91 

central figure in, 94 

Oberlaender 's classification, 93 

posterior urethra in, 106 
Hematuria, 235 
Herpes vesicalis, 228 
Hvdronephrosis, 278 
Hypertrophy of the prostate: 

cystoscopy in, 141 

endourethral treatment in, 135 

urethroscopy in, 109 



Indigo carmine test, 159 
Indirect cystoscopy, 168 
Infection by ureteral catheter, 293 
Infiltration, urethral : 

hard, 91 

soft, 89 
Injection into seminal vesicles, 129 



Lacuna? of Morgagni, 84, 95, 146 

obliteration of, 99 
Lavage, pelvic, 320 

in renal tuberculosis, 320 
Leucoplakia, A-esical, 204, 240 

urethral, 94 
Lithiasis, bladder, 364 

renal, 153 

ureteral, 154 
Lithotrity, 365 
Littre's glands, 84, 95, 132, 146 

cystic, 97 
Luys' urethroscope, 43 

cystoseope, 61, 224, 333 



M 



Meatotomy, ureteral, 375 
Mucosa, normal, of bladder, 149 
of uretlira. 84 



N 



Neck of hladder, 176, 202, 310 

polypi on, 270 
Neurasthenia, cured by endoscopy, 125 



Papilloma, vesical, 160, 163, 176, 202, 338 
Pelvis, I'enal, 

capacity of, 210. 313 
exploration of, 313 
Perforation of bladder, 142, 176, 236 
Periureteritis, 301 
Periurethral abscess, 98 
Phantoms, vesical, 167 
Photography, A-esical, 179 
Polypi, iir female urethra, 112 

on verumontanum, 66 

on A'esical neck, 270 
Posterior fossette, 101 
Posterior urethra, examination of, 76 
Postmontane space, 101 
Pregnancy, cystoscopy in, 241, 248 
Prismatic cystoscopy, 168 
Prostatic folliculitis, 101 

fossette, 52, 85. 105 

hypertrophy, cystoscopy in, 141 
endourethral treatment of, 135 
urethroscopy in, 109 

utricle, 52, 87, 109, 118 
Prostatitis, chronic 106, 122 
Pyelitis, treatment by lavage, 320 
Pyelography, 326 

Pyonephrosis, 153, 277, 281, 316, 358 
Pyuria, 235 



E 



Radium in Idadder tumors, 355 
Renal function, 285, 319 

infection by ureter catheter, 293 

lithiasis, 153 

pelvis, capacity of, 210 
exploration of, 313 

tuberculosis, 153, 281 



S 



Seminal vesicles : 

casts of, 123 

inflammation of, 124 

injection into, 129 

urethrovesicular reflex, 124 
Snare, in treatment of bladder tumors, 342 
Soft infiltration, 88, 101, 132 

central figure in, 90 
Solutions used in pelvic lavage, 323 
Spasm, urethral, 190 
Spermatocystitis, 100, 126 
Stricture : 

of ureter, 307, 377 

urethroscopic view of, 122, 132 
Suprapubic cystotomy, 329 
Syphilis of bladder, 188 



T 



Test, indigo carmine, 159 
Trabcculations of bladder, 214 
Trigone, ligaments of, 249 
Tul^ereulosis, renal, 153, 281 

pelvic lavage in, 320 

ureterovesical, 153 
Tuberculous cystitis, 203 

ulcerations of bladder, 258 

ureteral orifice, 258 
Tumors of Ijladder, 160, 205, 329, 358 

cystoscopy in, 205 

treatment of, 329 
Tumors of bladder neck, 336 

U 

Ulcerations of bladder, 258 
Ureter : 

calculi, 307 

catheters, 262 

catheterization, 210, 214, 254, 291 

accidents of, 293 

a demeure, 324 

and vesical deformities, 253 

dangers of, 291 

difficulties in, 291 

errors in, 298 

in children, 306 

indications for, 307 

Kelly's method, 267 
ejaculation, 158, 176, 210, 214 
exploration of, 374 
kink, 301 
lithiasis, 154 
jneatoscopy, 150 
obliteration, 301, 307 
orifices, 150, 176, 202, 210, 251 

anomalies of, 157 

aspects of, 150 

atresia of, 152 

dilated, 153 

edema of, 344 

golf-hole, 152 

in pregnancy, 214 

location of, 162 

prolapse of, 155 

tuberculosis of, 258 
radiography of, 326 
stricture of, 307 
Urethral glands, cystic, 97 
leucoplakia, 94 
spasm, 190 
Urethritis, chronic posterior, 106 
Urethroscopes : 

extei-nal illumination: 

advantages of, 35 

Antal, 31 

Auspitz, 33 

Casper, 30 

Clar, 32 

Desormeaux, 27 

disadvantages of, 35 

Fenwick, 32 

Griinfeid, 32 

Horteloup, 28 

Janet, 34 , . • . ' 



384 



INDEX 



Urethroscopes — Cont 'd. 

Kollmann-Weihe, 34 

Lang, 29 

Leiter, 28 

Nyrops, 29 

Otis, 30 

Schutze, 29 
internal illumination : 

Goldschmidt, 49 

Gordon, 38 

Kaufmann, 38 

Luys, 40, 43 

Nitze, 36 

Oberlaender, 36 

Kollmanu, 37 

Valentine, 37 

Wasserthal, 38 
for posterior urethra : 

Buerger, 50 

Goldschmidt, 47 

Le Fiir. 47 

Wossidlo, 50 
Urethroscopy : 
adrenalin in, 81 
aly])in in, 77 
central tigure in, 82 
contraindications to, 81 
history of, 27 
in chronic urethritis, 65 
in determining cure of urethritis, 68 
in hard infiltration, 88 
in soft infiltration, 88 



Urethroscopy — Cont'd. 

in prostatic hypertrophy, 109, 135 

in the female, 110 

lacunEs of Moigagni in, 84 

of normal urethra, 82 

of pathologic urethra, 88, 100 

posterior, 76, 100 

technic of, 70, 77 

Oberlaender and Kollmann, 69 
Urethrovesicovaginal fistula, 214, 236 
(Jrethrovesicular reflex, 124 **■ 
Uterine cancer, cystoscopy in, 207, 211 
Utricle, prostatic, 52, 87, 109, 118 

V "^ 

A^arix of bladder, 164, 207 
Vasopuncture, 126 
Vasotomy, 326 
Verumontanum, 87 

masturbator 's, 52, 109 

neurasthenia, in relation to the, 106 

normal. 87, 117 

polypi on, 106 

vegetations on, 106 

views of, 52, 66, 104, 146 
Vesical calculi, 364 

herpes, 228 

phantoms, 167 
Vesicular casts, 123 
A^csiculoctomy, 126 
Vesiculotomy, 126 



INDEX OF AUTHORS 



A 

Albarran, 154, 2(32, ?,0?, 
Albuquerque, 42 
Andre, 347 
Andrews, 26 
Antal, 31 
AscH, 42 
AuspiTZ, 33 
Ayres, 356 

B 

Bachrach, 347 

Baer, 180, 262 

Bar, 251 

Barbour, 251 

Barney, 347 

Bazy, 154 

Beer, 347 

Beleield. 246, 120, 126 

Berger, 180 

BiCKERSTETH, 62 

Binney, 347 
Blum, 347 
BoARi, 62, 364 
BoiiME, 347 
BozziNi, 25 
Braasch, 245, 328 
Brenner, 262 
Brown, 262 
BnucK, 55 
BucKY, 347 
B'UERGER, 50, 347 

Burns. 328 



C 



Cabot, 311 
Caspari, 341 
Casper, 31 
Cathelin, 305 
Clado, 42, 61 
colaneri, 217 
cottenot, 347 
Cruet, 207 
Crulse, 26, 54 

CULLEN, 60 



D 



Be Gouvea, 125 

De Ilyes, 326 

De Keersmaecker, 42, 88, 99, 342 

Delbet, 61 

De Mendoza, 42, 189 

Descjiaups, 294 

Desormeaux, 26 



Desvignes, 105 
d'Hallutn, 347 
DoMirER, 51 
Doyen, 347 



Elsner, 246 
ESCOMEL, 371 



F 



Fenwick, 32, 42, 158, 175 . 
Ferron, 62, 236, 291, 306 
Fisher, 25 
Fraisse, 42, 88, 100 
Frank, 305, 347 
Freudenberg, 262 
Fuller, 126 

FtJRSTENIIEIM, 26 

G 

Garceau, 58, 158, 302 
Gardner, 347 

Gautiiier, 62, 342, 364, 378 
Goldschmidt, 47 
Gordon, 38 
gorodichze, 265 
Grunfeld, 32, 56, 100, 269 
Gudin, 303 
guterbrock, 175 



H 



Hacken, 26 
Harpster, 136, 347 
Hartmann, 61. 297 
Heitz-Boyer, 28, 347 
Henriet, 364 
Henry, 42 
HoGGE, 59, 265 

HORTELOUP. 30 



Imbert, 262 
Israel, 295 



Jacoby--, 179 
Janet, 34, 61, 88, 100 
Jardon, 62, 374 
Jayle, 219 
Johnson, 81 
Joseph, 159 
JUDD, 347 



385 



386 



IXDF.X OF AUTHOliS 



K 



Kasenelsohn, 26 

Kaufmaxx, 38 

Keefe, 304 

Kelly, 57, 219, 246, 267, 30S, 319, 378 

KiDD, 327 

Klotz, 120 

KxoRE, 158 

Koch, 246 

Kollischer, 204 

KoLLMAXX, 34, 88, 99 

kouzxetzky, 299 

Keebs, 326 

Keotoszyxee. 327 

KUTTXER. 347 



Le Dextu, 40 
Le Fcr, 47, 364 
Legueu, 283, 297, 347 
Leiter, 36, 56 
Lepoutre, 347 ' 
Lewis, 59, 246, 378 

LuYS, 36, 40, 61, 120, 189, 217, 242, 246, 251, 
307, 320, 326, 371 



M 



Marculies, 294 
Mariox, 147, 332 
McCarthy, 347 
Millet, 246 

MlJEARD, 207 



N 



Nagelsciimidt, 347 

XiTZE, 36, 55, 168, 195, 207, 210, 223, 302, 331 

Xyeops, 31 

O 

Oberlaexder, 34, 36, 88, 99 
Oppexheimer, 354 
Otis, 31, 89 



Pasteau, 154 
Paul, 43 
Pawlick, 58, 269 
Pilciier, 347 
ProxTiK, 239 



Pozzi. 311 
Pulido-Martin, 371 



Eafin, 298 
EocKER, 175, 306 



Schlagixtaveit, 17' 
Schutze, 31 
Segalas, 26 
Siourta, 71 
StXCLAIR, 347 
Sx-ELL, 246 
Steix, 26 
Stephaxi, 242 
Sterx, 42 



Taverxier, 242 
Terrier, 230 
TixiER, 342 
Ti-FFIER. 242, 297 



U 



Uteau, 149 



Valentine, 37 
Verxeuil, 242 
Viertel, 207 
Violet, 207 
Voelcker, 159 
vox Friscii, 42 



W 



Wasserthal, 38 

Watson, 347 

Webster, 61 

Weixricii, 331 

WiEiiE, 34 

Wolbarst, 100, 347, 378 

Wormser, 42 

WossiDLO, 42, 50, 88, 100 



ZWEIFEL, 251 
ZUCKERKAXDL, 42, 200, 207 



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